NEEDS ANALYSIS AND CLIENT ADVISE RECORD

1 – Client information and details of current cover

Name and surname: Monthly income (Gross): R
ID number: Current medical scheme:
Number of dependents: Adults: Children: Name of option:
Cell: Tel: Years on this medical scheme:
Email Address: Gap cover YES NO Details:
2 – Needs analysis
Medical cover needs Need? Details (Name of condition or treatment) Would like cover for
Hospitalisation YES NO
Gap cover YES NO
Day-to-day, e.g. Doctors,
specialists, YES NO
medication/tests
Chronic conditions, needs YES NO
Any other? E.g. YES NO
Pregnancy
Do you have cover for your medical scheme premium should you be unable to earn an income due to death
and/or disability?
If so, please supply details
3 – Advise record
3.1 – Medical scheme, Gap cover & Premium cover options quoted and explained

3.2 – Medical scheme, Gap cover & Premium cover options recommended and why

3.3 – Specific medical scheme, Gap cover and/or Premium cover option requested by the client

3.4 – Please add details of recommended cover or cover chosen by the client after quotes and explanations.

3.5 – Client risk: Waiting periods, exclusions and penalties that might be applicable
Type Explained to client? Yes Comments:
Three month waiting period
12-month exclusion on pre-existing conditions
Late joiner penalty
THE CLIENT UNDERSTANDS THE FOLLOWING:

a. The underwriting procedure and final underwriting lay with the Medical Scheme, Short-term Insurance and Long Term Assurance underwriter.
b. A Late Joiner Penalty may be applied from age 35 and no proof of previous Medical Scheme membership as set out by the Medical Schemes Act. The Late Joiner Penalty will apply
to membership of all Medical Schemes.
c. A monitor of medical conditions will apply for 12 months if no proof of 24 months’ previous continuous membership is provided. The Medical Scheme may during this period
request medical reports to confirm that conditions were not pre-existing.
d. He/she is responsible to provide proof of previous Medical Scheme membership to avoid waiting periods or Late Joiner Penalties.
e. He/she is aware of co-payments on the chosen benefit option, and it will be for the clients’ expense if not covered by GAP Cover Insurance.
f. The exclusions of specified procedures on the chosen benefit option, for example joint replacements.
g. If applicable the representative can confirm formulary medication but the client must after admission to the Medical Scheme, apply for the chronic
disease as per the benefit option.
h. GAP Cover and Premium Cover Insurance is separate products from the Medical Scheme and there are separate premiums and stop/debit orders. The client also needs to cancel
these products separately.
i. Stop/Debit Orders can only be deducted on the dates as provided by product providers.
j. He/she can contact his/her representative or the offices of CFS for changes of personal detail, advice or intermediary service.
k. The chosen benefit options and the advice given was according to the client’s needs and budget.
l. Option changes can only be done at the end of each year, for the next year unless otherwise determined by the medical scheme.
m. Notice to cancel membership must be done in accordance with the rules of the product providers.
4 – Compliance information
Celsum Financial Services CC (CFS) is committed to providing the best possible advice and to meeting all the provisions of the
Financial Advisory and Intermediary Services (FAIS) Act in relation to the provision of advice. As a client, or prospective client,
we have a complaints resolution process in place for any queries or concerns relating to any advice given to you. Please do
not hesitate to contact your adviser, or send us an email to service @cfs-sa.co.za (Telephone 013 752 8221 or fax 086 603
2910). We will respond to your correspondence as soon as possible. If you are not happy with our response to your queries or
complaint, you can approach the Ombud at PO Box 74571, Lynnwood Ridge 0040 or at Telephone 012 348 3447 or email
info@faisonbud.co.za
5 – Financial services provider details
CFS is registered in terms of the FAIS Act as a Financial Services FSP number 44797. CFS is contracted with Medical Schemes and Insurance
Companies to market and distribute their products. All CFS’s representatives are appropriately accredited and registered respectively by the
Council for Medical Schemes and the Financial Services Board. CFS and its representatives are remunerated by way of statutory commission
payable by the medical scheme of 3% of the total monthly premium payable or R71.07, whichever is less per month (excluding VAT) in
respect of the Medical Scheme products, and by regulated commission in terms of the Long Term Assurance products, and the Short Term
Insurance Act to the amount of 20% of the monthly premium, in respect of the Insurance products. The representative may also negotiate a
monthly advisory fee with a client to provide a client with ongoing advisory and intermediary services. CFS received more than 30% of its
commission in the last year from one product provider and does not hold any shares in any product provider. Professional Indemnity
insurance cover of R1 000 000 is held by CFS and a policy on conflict of interest is implemented – a copy of the policy is available upon
request.

6 – Declaration by client

I elect to follow the advice in section 3.2 I do not elect to follow the advice in section 3.2 and have
Please mark with an (x)
been informed of the consequences of this decision.
Please mark with an (x)
The representative gave me the relevant information / product brochure of the medical scheme / insurance
product/s in which comprehensive disclosures are made including the benefits and contributions payable, as well
as the accreditation of the representative by CFS.

Signature of client: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7 – Declaration by the representative

I declare that the Needs Analysis is an accurate and complete record of the recommendations and advice that I
provided to the client based upon the information provided by the client. I hereby confirm that I am currently
working / working as an adviser under supervision, for the following products:

Medical scheme Life / Short Term

YES NO YES NO
Insurance
Product/s

Name of representative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature of representative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Code . . . . . . . . . . . . . . . . . . . . . . . . .

Any additional comments:

8 – Supervision
The advice given by the representative has been under supervision. The contents of the advice record have been
discussed between supervisor and the representative and the supervisor is satisfied that the advice given to the
client meets the requirements of FAIS.

Name of Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FAIS Licence FSP 44797 Council for Medical Schemes Accreditation ORG 4081