Econo Group Scheme Acceptance Form

ACCEPTANCE FORM

Thank you for choosing Hlalanathi Funerals for your all your funeral policy needs. Kindly select NEW policy or UPDATE policy and complete the details below. You can refer to the policy rules at any time by clicking here. Please note that required fields are marked with an orange asterisk *.

Is this a new policy or an update to your existing policy?*

NEW POLICYUPDATE POLICY

Policy Number:

The Policy Number is automatically assigned for NEW POLICY applications

Policy Number:

Please enter you existing Policy Number

Section 1. Personal Details of Main Member

Please complete the details of the main member below.

Title*

Full Name and Surname:*

Full NamesSurname

Address:*

City or Town*

Province*

Postal Code*

Identity Number:*

Birth Date:*

YearMonthDay

Main Member age must be between 21 and 79.

Cell Number:*

TodayDate

MainMemberAge

Section 2. Personal Details of Spouse

Please complete the details of your spouse below.

Title

Full Name and Surname:

Full NamesSurname

Identity Number:

Birth Date:

YearMonthDay

SpousePolicyAge

Spouse age must be between 21 and 79.

Section 3. Biological Children and Legal Guardianship

Please select the number of dependent children under the age of 21 that you would like to add to the policy, and provide their details below. Up to four (4) children are allowed for free. The maximum children you may add is six (6).

How many of your own children would you like to add to the policy?

Dependent Child 1 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Child1Age

Child 1 must be under 21 years of age.

Dependent Child 2 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Child2Age

Child 2 must be under 21 years of age.

Dependent Child 3 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Child3Age

Child 3 must be under 21 years of age.

Dependent Child 4 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Child4Age

Child 4 must be under 21 years of age.

Dependent Child 5 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Child5Age

Child 5 must be under 21 years of age.

Dependent Child 6 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Child6Age

Child 6 must be under 21 years of age.

IsChild5Filled

IsChild6Filled

Policy Cover and Premium - Excluding Extended Members

Please select your desired cover amount from the dropdown list below. If you selected a spouse, he or she will also receive the same cover amount you selected. The premium amount will be automatically calculated.

Cover Amount (R):*

In Rands

Cover Amount (R):*

In Rands

Premium:

Rand amount

Premium Amount (R):

In Rands

Section 4. Extended Members

Please select the number of extended members you would like to add to the policy, and provide their details below. Up to six (6) extended members are allowed.

How many extended members would you like to add to the policy?

Extended Member 1 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Cover Amount (R):

In Rands

Cover Amount (R):

In Rands

Premium:

In Rands

Member1Age

Extended Member 1 age must be between 21 and 79.

Extended Member 2 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Cover Amount (R):

In Rands

Cover Amount (R):

In Rands

Premium (R):

In Rands

Member2Age

Extended Member 2 age must be between 21 and 79.

Extended Member 3 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Cover Amount (R):

In Rands

Cover Amount (R):

In Rands

Premium (R):

Rand amount

Member3Age

Extended Member 3 age must be between 21 and 79.

Extended Member 4 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Cover Amount (R):

In Rands

Cover Amount (R):

In Rands

Premium (R):

In Rands

Member4Age

Extended Member 4 age must be between 21 and 79.

Extended Member 5 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Cover Amount (R):

In Rands

Cover Amount (R):

In Rands

Premium (R):

In Rands

Member5Age

Extended Member 5 age must be between 21 and 79.

Extended Member 6 Details

Surname:

Full Names:

ID Number:

Birth Date:

YearMonthDay

Cover Amount (R):

In Rands

Cover Amount (R):

In Rands

Premium (R):

In Rands

Member6Age

Extended Member 6 age must be between 21 and 79.

Total Policy Premium

TotalPremiumCalc

Rand amount

Total Premium Amount (R):

In Rands

Beneficiary Details

Nominated Beneficiary Name:*

Nominated Beneficiary ID:*

6 Months Waiting Period

Section 5. Declaration and Signature

I the undersigned, hereby accept the membership and benefits, as indicated, on the Econo Group Scheme. I hereby declare and warrant all information supplied herein, to be true and correct. I am aware that any non-disclosure or misrepresentation of information, which is material to the determination of the risk by The Underwriter, may lead to the policy being declared null and void in which case all premiums paid will be forfeited. I am certain that the product which I am applying for meets my needs and feel that I have all the necessary information in order to make an informed decision in respect of the purchase thereof. The Terms and Conditions and the Intermediary Disclosure Document were made available and explained to me. Acceptance of this policy is subject to verification done by Safrican in terms of the Financial Intelligence Centre Act (Act 38 of 2001).

Do you have an existing funeral policy with Econo Group Schemes?

YESNO

Have you cancelled or do you intend to cancel an existing policy in order to take out this one?

YESNO

Signature of the Main Member*

Signature Date and Time

Section 6. ID Document Upload

Please upload (or a take a picture of) the ID Document/s for ALL policy members, including spouse, children and extended members if relevant.

Click below to choose your ID Document file:

The Terms and Conditions applicable to this policy, are explained in your policy document. Subject to the terms of the Insurance Act, you have 30 days after receipt of the summary of the policy contract (as intended in Article 48 of the Act), to cancel your policy shouldthere be any non-compliance with the laws governing your policy.

Enquiries or complaints, which are not resolved to your satisfaction, may be referred to:

Ombudsman for Long-term insurance, PO Box 45007, Claremont, 7735

Registrar of Long-term insurance, Financial Services Board, PO Box 35655, Menlo Park, 0102

By clicking the "Submit" button below, you certify that you have read and understood the Terms and Conditions summary and POPI Information Act, and that the above information is correct and accurate to the best of your knowledge. All information will remain confidential.

I have read and understand the Terms and Conditions summary.*

YESNO

I have read and understand the POPI Information Act.*

YESNO