E - WILL APPLICATION
Your Information
Name
*
Surname
*
ID Number
*
E-mail :
*
ex: myname@example.com
Phone Number
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cover Required
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( X )
E - Will Single 18 to 65 - R5000.00 Cover
89.00
ZAR
E - Will Single 65 to 75 - R5000.00 Cover
104.75
ZAR
E - Will Single 75 to 85 - R5000.00 Cover
121.00
ZAR
E - Will 18 to 65 Family - R5000.00 Cover
100.00
ZAR
E - Will Family 65 to 75 - R5000.00 Cover
115.00
ZAR
E - Will Single 18 to 65 - R10 000.00 Cover
99.65
ZAR
E - Will Single 65 to 75 - R10 000.00 Cover
122.65
ZAR
E - Will Family 18 to 65 - Cover R10 000.00
129.00
ZAR
E - Will Family 65 to 75 - R10 000.00 Cover
134.00
ZAR
E - Will Single 18 to 65 - R20 000.00 Cover
111.65
ZAR
E - Will Family 65 to 75 - R20 000.00 Cover
141.65
ZAR
Bank Details
Name
Type Of Account
Please Select
Cheque
Transmission
Savings
Type a question
ABSA Bank - 632005
African Bank Limited - 430000
Bidvest Bank Limited - 462005
Capitec Bank Limited - 470010
FNB (First National Bank) - 250655
Investec Bank Limited - 580 105
Nedbank Limited - 198675
SA Post Bank (Post Office) - 460 005
Standard Bank of South Africa - 051 001
Thyme Bank - 678 910
UBank - 431010
Old Mutual - 462005
Debit Date
1st
7th
15th
25th
31st
14:Terms and conditions
Please check the following boxes to indicate your understanding and agreement:
*
I agree to allow E - Will and its affiliates to use my information for marketing purposes and for purposes of managing the products taken
My email address will be added to the Newsletter list
15: E-Signature
By signing (typing your legal name) in the space below, you agree to the collection, use and processing of the personal information you provide to E - Will in this form for the purposes of organization administration and inclusion of your contact information to product providers. By signing, you are also certifying that all information is correct and that you are the person completing this application. You also agree that your information may be accessed and used by E - Will its affiliates and its staff. You understand that the majority of the data requested in this application is necessary for administrative and planning purposes and that the failure to provide this information may prevent your application from being properly processed or the services been supplied.
E-Signature:
*
Submit
Should be Empty: