Application Form

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Title

First name*

Last name*

Email*

Birthday*

Gender*

Male

Female

Smoker*

Yes

No

Highest Qualification

(for e.g. Matric, Diploma, Degree, Honours, Masters, PHD)

Occupation

Marital Status

Monthly Income before Tax*

Medical Aid

If Yes, Company name, membership number and how many members?

Wellness Programme

If Yes, Company name, membership number and how many members?

Type of Cover: Personal/Business

Benefit Name

Death

Selected Benefit Amount & Notes

Benefit Name

Disability

Selected Benefit Amount & Notes

Benefit Name

Severe Illness

Selected Benefit Amount & Notes

3 Hartshorne Avenue

Johannesburg

South Africa

+27 11 026 1203

WKIA Pty Ltd is an authorised

Financial Services Provider (42754)

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