Requirements for Life insurance, Disability insurance and Insurance for dread disease:

1. Applicants must provide proof of medical aid coverage. (If not on medical aid, we can arrange it.)
2. Individual earnings must exceed R10 000 per month and/or applicant must be in possession of a certificate of higher learning qualification.
3. Applicant must provide proof of use of anti-retro viral medication.
4. Accurate and complete information on the application form must be provided. Incomplete and inaccurate information can lead to the dismissal of the request.
5. Applicant must be a RSA citizen.
6. Applicant must be older than 16 years of age.

(HIV Sure practices a strict code of confidentiality regarding any and all personal information unless otherwise requested by clients in writing, or if bound by law to disseminate personal information.)

Name & Surname
ID Number
Telephone
Cellphone
Fax
E-mail Address
Gender
Smoker	Yes No
Occupation
Qualification
Income p/m	Select 10 000 - 15 000 16 000 - 20 000 21 000 - 25 000 More Other Other
Time spend in occupation on monthly basis (must equal 100%)
Admin	%
Travel	%
Supervisor	%
Manual Labour	%
Last Virale Count
Last CD Count
Date of first HIV Positive Test
Enquiry
Key in number
	I declare that all given information is correct and true.