Staff Policy Application Form

Staff Policy Application Form
By completing this form, I take note of and agree to the following:
1. I am an employee of Wisani Burial Services or NLA Funeral Services.
2. Staff price will only be granted for Wisani Plan E or NLA Achiever plan.
3. Staff members have the option to add Tombstone and/or Top-Up cover to their policies.
4. Premium deductions will be facilitated through Payroll. The total deduction will be 50% of the staff member's policy.
5. If there is an error on the deduction amount, where more or less than 50% of the premium is deducted, it is the staff member's own responsibility to inform both the Admin Department and the Payroll Department of this error.
6. In case of an underpayment due to a deduction error, the staff member will still be liable for any outstanding amount that is still due on their policy.
7. Deductions will only be allowed through Payroll. No other payment method will be allowed on staff policies.
8. Each staff policy will be assigned a unique policy number, which will indicate that it is a staff policy.
9. Should a staff member leave the company for whatever reason, the policy holder will have to pay full price on their policy from the first month that they are no longer an employee. They will also receive a new policy number indicating that their policy is now a normal policy and no longer a staff policy.
10. All permanent employees will qualify for staff price on their policy.
11. Part-time employees will only qualify if they have been with the company for at least 36 months and have a stable income for at least 12 months that is enough to cover a policy deduction.
Please see memo M056/24 for further information.
Employee Information
Name*

First NameLast Name
Employee Number*
Phone Number*
Please enter a valid phone number.
Appointment date*

DayMonthYear
Date
Period worked at the company*
Years and months that you have been employed by the company
Policy Information
I want to:

Apply for a new staff policyApply for staff price with my current policyCancel my staff policy
Current policy number (If applicable)
Policy inception date (If applicable)

DayMonthYear
Date
Current policy premium amount (If applicable)
Preferred option*

Wisani Plan EWisani Plan BNLA AchieverCancellation
Acknowledgement
I hereby confirm that the above information is correct and true to the best of my knowledge. I further accept that disciplinary steps can be taken against me for any false information provided that may lead to an incorrect policy deduction.

No staff price will be awarded without a full signature. Employee will sign in full in the allocated space. Applications that are not signed, signed with an "X", signed with a dot, signed with only initials, or anything other than a full signature, will be rejected immediately.
Signature*

Clear
Should be Empty:

Staff Policy Application Form

Employee Information

Policy Information

Acknowledgement