066E

Effort electrocardiogram

Plan number 45647069X9

Particulars of life insured

Must be completed by the intermediary or life insured.
Surname MRS HLATSHWAYO
First name and further initials TEBOGO,G
Identity number/Passport number 6708220370086 (Compulsory)
Note: Passport number only if not in possession of a valid RSA identity document.
Date of birth 1967-08-22
/ / (dd/mm/ccyy)
Address 852 GUGUSHE STREET, 1818 PROTEA NORTH

Signature of life insured

Particulars of intermediary
Name and surname LUKOPE, TB(Tembalethu) Intermediary code 00012904
Telephone number ( )

Particulars of examiner
Must be completed by the examiner.
First name, further initials and surname
Telephone number ( ) Fax number ( )
Qualifications
Date of procedure/examination/questionnaire / / (dd/mm/ccyy)
Are you the life insured's usual medical practitioner? Yes No
I confirm that this examination has been conducted in my surgery by myself and that photographic identity was supplied
according to ASISA protocol.

Signature of examiner

Compensation payable
First name, further initials and surname
Full name of practice or partnership
Address
Practice code VAT Registration number
Tariff code: 1302 Fee payable according to ASISA tariff R

Effort electrocardiogram
We have received an application for life insurance from the person as indicated on the front page. To be able to consider the
application, we require an effort electrocardiogram. We will appreciate it if you can do this procedure according to the
guidelines on page 2.
Important: The applicant/life insured has authorised us to obtain this information from you (and has requested you to provide
us with this information) and to share it with other life offices direct, or through ASISA for purposes of underwriting and/or
claims assessment. In terms of ASISA protocol the applicant/life insured may enquire about information held by ASISA. Such
information will be made available to him/her by his/her nominated medical practitioner.

Sanlam 05/2013
Licensed Financial Services and Registered Credit Provider (NCRCP43) 1
Plan number 45647069X9

Procedure for effort electrocardiogram

1. Resting, leads 1, 11, 111, 111(R) (i.e. STD 111 with sustained inspiration), AVR, AVL, AVF, AVF(R) (i.e. AVF with
sustained inspiration) and chest leads V1 to V6.
2. Subject the insured to sufficient effort (exercise) to obtain a pulse rate of at least 120 per minute or 50% more than the
resting rate.
To make sure that there is a gradual increase in the pulse rate, the exercise should be completed in at least 3 minutes.
3. Please repeat the electrocardiogram:
 immediately after effort;
 3 minutes after effort;
 6 minutes after effort
Note: Any method giving a satisfactory pulse acceleration will be acceptable.

Important:
1. Ensure that your apparatus has been properly standardised. An impulse of 1mV should produce a right-angled
standardisation signal exactly 10 mm high. This should be carried out before production of the E.C.G. commences.
2. Make sure that the speed of the paper is correct. (25 mm/sec.)
3. Ensure a straight base line by allowing the needle to settle before the paper starts moving.
4. Make sure that arm and leg electrodes have not been switched and mark each deduction clearly.
5. Do not cut or mount the ECG which should bear the date of the ECG, the insured’s name and signature as well as your
own.
6. Do not conduct the effort test in the following cases:
 If the life insured objects to the test.
 If you have observed risks or contra-indications in the life insured.
 If substernal or chest pain, excessive tiredness, dyspnoea or bronchospasm develops while the life insured is busy with
the exercises.
 If the ECG shows deviations before effort.

If you have decided not to produce an ECG, please state the reason briefly.

Symptoms
Did the life insured show any symptoms as a result of the exercise? Yes No
If "Yes", please give details.

E066 2
Sanlam 05/2013 Licensed Financial Services and Registered Credit Provider (NCRCP43)