Funeral Policy online application.

MAIN MEMBER DETAILS:

Today's date: (Inception date will be the 1st day of the next calendar month.) Title: Surname and first names of main member: Please attach main member copy of ID: ID number of main member: Date of birth: Main member age: Postal address: E-mail address: Cellphone number:

BENEFICIARY DETAILS:

Title of beneficiary: Surname and name of beneficiary: ID number of beneficiary: Postal address of beneficiary: Email address of beneficiary: Cell phone number of beneficiary:

PRODUCT DETAILS:

Principle member cover: Type of plan: (Family includes spouse and/or children)

DEPENDANT DETAILS: (Spouse under 65 years and up to 5 children under 21 years)

Name	Surname	ID Number	Date of Birth	Relationship

EXTENDED MEMBER DETAILS: (Parents, Grandparents, Uncles and Aunts, R10 000 and R20 000 cover.)

Name	Surname	ID number	Date of birth	Relationship	Age	Cover amount	Premium

PREMIUM DETAILS: (R10 debit order fee included in total premium)

Principal member premium (ZAR)	Extended member premium (ZAR)	Debit order fee (ZAR)	Total monthly premium (ZAR)
		10

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AUTHORISED ESSENTIAL FUNERAL SERVICE PROVIDER – K20155367341 (See here)