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Personal advice backed by 20 years of insurance and financial services experience.

FSP 51909

01Our SolutionsExplore all confirmed service areas↗ 02Life CoverFinancial protection for your loved ones↗ 03Funeral CoverHelp reduce the financial burden on family↗ 04Legal CoverCover for qualifying legal matters↗

Claims Support Contact

Speak to us069 313 2185 Get a Quote↗

20 Years' Industry Experience FSP 51909

Home01 About02

Our Solutions Life Cover Funeral Cover Legal Cover

Claims Support04 Contact05

Get in touch 069 313 2185 info@nketels.co.za Get a Quote↗ Policies & Compliance

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NKETE LIFE SOLUTIONS

How can we help?

Leave your details and a Nkete adviser will contact you.

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Full Name *

Phone Number *

Email Address

What can we help you with? *

Message

Prefer to call? 069 313 2185

NKETE LIFE SOLUTIONS

Life Cover Application

Complete the client disclosure checklist in six clear steps.

LIFE COVER

Life Cover Application

Complete your Life Cover application securely in a few simple steps.

016 clear stepsOne section at a time

02Review before submittingCheck your information first

03Personal supportHelp is available if needed

Nkete Life Solutions FSP 51909 Personal Support Available

Need help before you continue? Call 069 313 2185

Step 1 of 6 Personal Details

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Personal Information

Tell us about the person applying for cover.

Full Name *

ID / Passport *

Date of Birth

Gender

Citizenship

Marital Status

Dependants

Cellphone

Beneficiaries (names & relationship)

Insurable interest

Cover & Financial

Provide the cover and financial information requested in the NNFS checklist.

Cover type

Sum assured (R)

Purpose of cover

Source of income

Gross monthly/annual income

Existing individual policies

Employer group cover

Occupation, Activities & Lifestyle

Complete the work, activity and lifestyle disclosures.

Occupation

Employer

Work duties description

Occupation & Duties

Security / armed / law enforcement Aviation-related duties

Hazardous Sports & Hobbies

Motor / bike racing Scuba / commercial diving Skydiving / paragliding Rock climbing / mountaineering Firearms (non-recreational)

Other high-risk activity (details)

Lifestyle & Build

Height (cm)

Weight (kg)

Avg alcohol per week (units)

Tobacco / nicotine use

Yes No

Last nicotine use (date)

Recreational drug use

Yes No

Medical Disclosure

Answer each medical question Yes or No.

Heart / cardiovascular *

Yes No

Lung / respiratory *

Yes No

Stomach / bowel / kidney / liver *

Yes No

Neurological (epilepsy, stroke, MS) *

Yes No

Bone / joint / muscle / spine *

Yes No

Mental health (depression, anxiety) *

Yes No

Chronic conditions (diabetes, hypertension) *

Yes No

Medical tests / investigations *

Yes No

Cancer / tumours / leukaemia *

Yes No

Surgery / hospitalisation / device *

Yes No

If any Yes, provide details (diagnosis, dates, treatment, etc.)

Family Medical History, HIV & Travel

Complete the remaining disclosures from the NNFS checklist.

Family Medical History

Heart disease / heart attack Stroke Cancer Diabetes Kidney disease

Details (age at diagnosis / death)

HIV Disclosure

Ever tested HIV-positive?

Yes No

Date of diagnosis

Current treatment status

CD4 / viral load

Willingness to undergo HIV testing

Yes No

Travel & Residency

Permanently outside SA Travel to high-risk countries

Planned emigration / extended abroad

Review & Declaration

Check your information before submitting.

Declaration & Consent

All answers true, complete & accurate Consent to access medical records Consent to underwriting assessment POPIA consent for data processing

I understand that incorrect or incomplete information may affect my policy or claims.

Client Name *

Signature (type full name) *

Date *