Financial Needs Analysis
Syllabis Financial Needs Analysis
Full Name
Personal Information
Email Address
Personal Information
Telephone Number
Personal Information
Personal Information
Your age?
0-17
18-25
26-35
36-45
46-55
56-65
66-75
76-85
86-95
96+
Please Select
Your gender?
Male
Female
Gender Neutral
Other
I'd prefer not to say
Please Select
What is your relationship status?
Single
In a relationship
Married
Divorced
Remarried
Please Select
What is your current place of residence?
I own the house, apartment or townhouse I stay in.
I am renting to stay in my current place of residence.
I am staying at my current place of residence for free, but I don't own it.
I am staying with my parents.
Please Select
How many dependents do you have? This could be children, relatives, friends or loved ones that are dependent on you with regard to finances.
0
1
2
3
4+
Please Select
Please select all financial/insurance products you currently have.
Retirement Annuity
Life Insurance
Insurance
Disability Cover
Severe Illness Cover
Income Protection
Funeral Cover
Go Cover
Credit Life Cover
Health Solutions
Short Term Insurance
Please Select
Do you have a will?
Yes
No
I have a will but it has not been updated in a long time.
Please Select
On a scale of 1 to 10, how dangerous is your daily life? (factors effecting this could be your mode of transport, your occupation, your residential area, etc...)
1
2
3
4
5
6
7
8
9
10
Please Select
Do you suffer from any major disabilities?
Yes
No
Please Select
Do you suffer from any chronic or major illnesses?
Yes
No
Please Select
How often do you exercise?
Daily
Weekly
Every two weeks
Once a month
I don't really exercise
Please Select
Financial Information:
What is your highest academic qualification?
Grade 1-11
NSC certificate
Diploma
Degree
Post-graduate degree
Please Select
What is your primary occupation?
Personal Information
How many sources of income do you have?
0
1
2
3
4+
Please Select
What is your monthly income?
Above R40 000
Please Select
Date Field
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