302E

The General Practitioner

Plan number 45647069X9

Particulars of life insured

Surname MRS HLATSHWAYO
First name and further initials TEBOGO

Address 852 GUGUSHE STREET, 1818 PROTEA NORTH

Date of birth 1967-08-22

/ /
Identity number/Passport number 6708220370086
(Note: Passport number only if not in possession of a valid RSA identity document.)

Particulars of intermediary
Name and surname LUKOPE, TB(Tembalethu)
Intermediary's code 00012904

Dear Doctor
Thank you for agreeing to examine the above-mentioned client. Before you perform the examination, please determine the
client's identity with a photographic proof of identity. Indicate on the enclosed form - or on the report of your findings if no form
is available - what type of proof of identity was given.
To consider a proposal for insurance for our client we require the following as indicated:
Item nr
✔ 1102 Medical report on the enclosed AE2230 form.
1103 Short medical report on the enclosed AE2681 form. (A qualified registered sister in your
service can also complete this report.)
1105 Heart report on the enclosed AE63 form.
1301 Resting ECG (at least 12 leads).
✔ 1302 An effort ECG according to our procedure (enclosed).
1402 The enclosed questionnaire, completed in full.
1106 Three blood pressure readings (only one visit).
1306 Pulmonary function tests with a vitallometer (minimum information required: FVC, FEV1,
FEV1%). (Procedure enclosed).

Please use the enclosed self-addressed envelope to send the report to the relevant Sanlam office. Seal the envelope by
signing in the block on the reverse side.
Sanlam Life will remunerate you for the cost of the examination/report, in accordance with the agreed-on tariffs for medical
services.

Thank you for your co-operation.

Yours sincerely

Dr Marion Morkel
MB.ChB, DOH
Chief Medical Adviser

Sanlam 06/2017
Licensed Financial Services and Registered Credit Provider (NCRCP43) 1