Financial Needs Analysis Questionnaire
Please provide your details to help us assess your financial needs. All information is used solely for your personalized Financial Needs Analysis and is protected in accordance with POPIA. Your data will not be shared without your explicit knowledge and consent.
Personal Details
Title
*
Please Select
Mr
Mrs
Ms
Miss
Dr
Prof
Other
Full Name (as per your ID/Passport)
*
First Name
Last Name
ID/Passport Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Gender
*
Female
Male
Are you a smoker
*
Yes
No
Marital Status
*
Single
Engaged
Married
Divorced
Windowed
Do you have dependents?
*
Yes
No
If, 'Yes', how many dependents do you have ?
*
Please list each dependent's name and date of birth
Type a question
Do you have a will
*
Yes
No
Are you a member of a medical aid scheme
*
Yes
No
Occupation & Education
Education Level
*
No Matric
Matric
3 -4 Year Technikon or Teachers College Diploma
Undergraduate University Degree
Post-Graduate Qualification
Future Professional
I am
*
Please Select
Employed
Self-employed
Occupation
*
Employer
*
Which applies to your occupational duties
*
Admin
Travel
Supervisory
Heavy Manual Labour
Income & Expenditure
Understanding your income and spending helps us create a personalized, comprehensive plan for your current and future financial goals. All personal information shared is treated with strict confidentiality and protected in line with POPIA.
Monthly Gross Income
*
This is your Income before deductions
Monthly Net Income
*
Do you have other sources of Income?
*
Yes
No
If, 'Yes', how much monthly income do you receive from those sources
*
Estimated Monthly Expenses
*
Current Savings
*
Current Investments
*
Assets & Liabilities
Assets and Liabilities form part of your personal economy, we need to be aware of both to be able to safeguard secured assets and settle all liabilities when completing your financial plan. All personal information shared is treated with strict confidentiality and protected in line with POPIA.
Which of the following assets do you own?
*
Primary Residence
Other Property
Vehicle/s
Investments(Unit Trusts, Share Investments, Endowments, etc)
Savings account/Fixed Deposit
Firearms
Jewellery
Livestock
Business Holdings
Furniture
Other
If, 'Other' Please specify
*
Estimated Total Value of Assets
*
Which of the following liabilities do you have?
*
Bond/Home Loan
Vehicle Loan
Credit Card
Overdraft
Personal Loan
Other Liability
If, 'Other' Please specify
*
Estimated Total Outstanding Value of Liabilities/Debts
*
Existing Provisions/Cover
We must account for the provisions and/or cover you have already made to identify and solve for any gaps in your current plan.
Do you currently have any of these provisions in place?
*
Life Cover
Disability Cover
Income Protection
Dread Disease Cover
Business Assurance
Does your employer provide you with benefits like Retirement Provisioning or other group cover
*
Yes
No
Please specify the amount of cover for each:
*
Financial Goals & Objectives
Your goals and objectives are central to the plan we develop, ensuring it reflects what matters most to you. All personal information shared is treated with strict confidentiality and protected in line with POPIA.
Which type of Financial Protection is most important to you currently
*
Cover to protect my family should I pass away
Cover to protect my ability to earn an income should I become unable to work
Cover to protect my lifestyle should I become critically ill
Providing for my children's education
Retiring comfortably
Paying off my debts should I pass away, become disabled or critically ill
Growing and protecting my wealth through investments
Unsure, I need help deciding
What are your long-term financial goals (5+ years)
*
At what age to you plan to Retire
*
What is your desired monthly income at Retirement
*
For how long would you like to receive that monthly income
*
What is your budget for ensuring the goals and objectives listed above are met?
*
Set up your appointment with Lona Gusha
*
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