APPLICATION FOR MEMBERSHIP
1 + 5/9/13 TRADITIONAL BURIAL PLAN
AGENT CODE
PRINCIPAL MEMBER
ID number
*
Enter your 13 Digit RSA Identity Number
Name
*
First Name(s)
Middle Name
Surname
Phone Number
*
Please enter a valid phone number.
Format: 000 000-0000.
Email address
example@example.com
Occupation
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal Code
Province
*
Please Select
Eastern Cape
Freestate
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
Northern Cape
Northwest
Western Cape
COVER SELECTION OPTIONS
Unclick the selection to change the option.
COVER PACKAGE OPTION
*
Please Select
MOPANE
MORULA
BOABAB
Mopane
R 230.00 (1+5)
R 335.00 (1+9)
R 425.00 (1+13)
Morula
R 300.00 (1+5)
R 395.00 (1+9)
R 490.00 (1+13)
Baobab
R 455.00 (1+5)
R 530.00 (1+9)
R 615.00 (1+13)
Include Overage Dependants
No
Yes
Include Overage Dependants
No
Yes
Number of Overage Dependants (1+5)
Please Select
None
1
2
3
4
5
Will cover include Overage Dependants?
Number of Overage Dependants (1+9)
Please Select
None
1
2
3
4
5
6
7
8
9
Will cover include Overage Dependants?
Number of Overage Dependants (1+13)
Please Select
None
1
2
3
4
5
6
7
8
9
10
11
12
13
Will cover include Overage Dependants?
Number
Total Monthly Premiums (Rands)
NOMINATED FAMILY DEPENDANTS (MAXIMUM ENTRY AGE 84)
Name 1
First Name
Surname
Date of Birth 1
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ID Number 1
Enter your 13 Digit RSA Identity Number
Name 2
First Name
Surname
ID Number 2
Enter your 13 Digit RSA Identity Number
Name 3
First Name
Surname
ID Number 3
Enter your 13 Digit RSA Identity Number
Name 4
First Name
Surname
ID Number 4
Enter your 13 Digit RSA Identity Number
Name 5
First Name
Surname
ID Number 5
Enter your 13 Digit RSA Identity Number
Name 6
First Name
Surname
ID Number 6
Enter your 13 Digit RSA Identity Number
Name 7
First Name
Surname
ID Number 7
Enter your 13 Digit RSA Identity Number
Name 8
First Name
Surname
ID Number 8
Enter your 13 Digit RSA Identity Number
Name 9
First Name
Surname
ID Number 9
Enter your 13 Digit RSA Identity Number
Name 10
First Name
Surname
ID Number 10
Enter your 13 Digit RSA Identity Number
Name 11
First Name
Surname
ID Number 11
Enter your 13 Digit RSA Identity Number
Name 12
First Name
Surname
ID Number 12
Enter your 13 Digit RSA Identity Number
Name 13
First Name
Surname
ID Number 13
Enter your 13 Digit RSA Identity Number
BENEFICIARY
Name
First Name
Last Name
Relationship
ID number
Enter your 13 Digit RSA Identity Number
Phone Number
Please enter a valid phone number.
Format: 000 000-0000.
PAYMENT OPTIONS
Select Preferred Option
*
CASH
EFT
DEBIT ORDER
DEBIT ORDER BANK DETAILS:
Name of Account Holder
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: 000 000-0000.
Bank Name
Please Select
Absa Bank
African Bank
Bank of Athens
Barclays Bank
Bidvest Bank
Capitec Bank
Discovery Bank
First National Bank
FirstRand Bank Limited
HSBC Bank
Investec Bank
Mercantile Bank
Nedbank
Old Mutual
Rand Merchant Bank
RMB Private Bank
Sasfin Bank
SA Post Bank
Standard Bank
Standard Chartered Bank
Tyme Bank
Universal Branch Code
Please Select
632-005 (Absa)
430-000 (African Bank)
410-506 (Bank of Athens)
590-000 (Barclays)
462-005 (Bidvest)
470-010 (Capitec)
679-000 (Discovery)
250-655 (FNB)
201-419 (FirstRand)
587-000 (HSBC)
580-105 (Investec)
450-905 (Mercantile)
198-765 (Nedbank)
462-005 (Old Mutual)
261-251 (RMB)
222-026 (RMP Pvt)
683-000 (Sasfin)
460-005 (PostBank)
051-001 (Standard)
730-020 (Std Chatered)
678-910 (Tyme Bank
Account Number
Type of Account
Please Select
Current/Cheque
Savings
Transmission
Initial Amount
*
Joining Fee + Premium
Date
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date of Initial Debit Order
Monthly Amount
*
Monthly Premium Payable
Day of the Month
01st
07th
15th
25th
Month End
COVER PREMIUM INCEPTION
Inception Date
Month
Please Select
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Please Select
23
24
25
26
27
28
29
30
Main Member Signature
Date
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Preview PDF
Print Form
Save
Submit
Clear Form
Should be Empty: