Application Form

PAYMENT METHOD

Bank Debit Order

Payat

Cash

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MAIN MEMBER DETAILS

Policy number

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Inception date

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Cover amount

Premium amount

Full name

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Surname

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ID number

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Full address

Address Line 1

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Address Line 2

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City

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Postal Code

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Country

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Contact numbers

Cellphone

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Home

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Work

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Email address

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PRODUCT DETAILS

Type of Plan:

Family

Society

Individual

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DETAILS OF EXTENDED FAMILY MEMBERS

Name

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Surname

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Relationship

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ID Number

Sum Assured

Supplementary Benefit

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NOMINATED BENEFICIARIES

Initials

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First Name

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Surname

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Birth date/ID number

Relationship

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Benefits

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I, the applicant/policy holder under this policy, in the event of my death, hereby nominate the above-mentioned person as the beneficiary in terms of this policy, to receive benefits payable under this policy. I hereby indemnify my Scheme, _____________________ or the underwriter against any claim/s by myself or by any third parties in respect of the payment of the policy benefits to the beneficiary. I hereby acknowledge and understand that unless I instruct differently in writing, the benefits will be received by _____________ and payment will be forwarded to me or my nominated beneficiary.

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WAIVER OF WAITING OF WAITING PERIODS QUESTIONAIRE

Are you taking this policy to replace a funeral policy that was cancelled within 2 months before taking this new one?

Disclaimer: In the event that the main member takes cover higher than their previous cover, they will be subjected to a waiting period.

Yes

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Name of insurer

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Cover start date

Cancellation/lapse date

Are you covering the same life/lives that were covered on your previous funeral policy (Principal member)?

If "No" full waiting period will be imposed.

Yes

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PREMIUM PAYER DETAILS

Personal information (for the premium payer)

Full name

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Surname

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ID number

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Full address

Address Line 1

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Address Line 2

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City

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Postal Code

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Country

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Contact numbers

Cellphone

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Work

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Home

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Email address

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Total premium amount