• WELCOME

    Contact: 012 880 5456 / 065 820 3636

  • Main Member Details

  • Format: 000000 0000 000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Which is your nearest town*

  • TRANSPORT COVER

  • TRANSPORT COVER.

    This Cover helps if you have a loved one living outside our operating area.

    OR

    You need groceries to be delivered where you need them

  • Would you like to add Transport cover?*
  • Would you like to add additional family cars @ R40 per car, per month?*

  • COMPULSORY TRANSPORT COVER 

    IF YOU HAVE CHOSEN OTHER, TRANSPORT COVER IS COMPULSORY.

    TO AVOID BEING CHARGED FOR EXCESS KILOMETERS, IT TIME OF SORROW 

  • Cover Selection

    Please choose the cover
  • How many people would you like to cover*
  • Please Select the Cover 5*
  • Please Select the Cover 9*
  • Please Select the Cover*
  • Transport cover

  • Dependants Details

  • DO YOU WANT TO ADD DEPENDANTS*
  • Date of birth Dependent 1
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 2*
  • Date of birth Dependent 2*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 3*
  • Date of birth Dependent 3*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 4*
  • Date of birth Dependent 4*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 5*
  • Date of birth Dependent 5*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 6*
  • Date of birth Dependent 6*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 7*
  • Date of birth Dependent 7*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 8*
  • Date of birth Dependent 8*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 9*
  • Date of birth Dependent 9*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 10*
  • Date of birth Dependent 10*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 11*
  • Date of birth Dependent 11*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 12*
  • Date of birth Dependent 12*
     - -
    2 digit month, 2 digit day, 4 digit year
  • DO YOU WANT TO ADD DEPENDANT 13
  • Date of birth Dependent 13*
     - -
    2 digit month, 2 digit day, 4 digit year

  • BENEFICIARY

    Please nominate at least one beneficiary
  • Format: (000) 000-0000.

  • METHOD OF PAYMENT

    After submitting , you need to make online payment as the first premium for your form to be accepted,you will be redirected to payment portal
  • How will you be paying your monthly premiums?*
  • Please in, if you choose debit order
  • Which day of the month should CHABA DI KOPANE start debiting your account? There same amount based on the cover you chose will be debit every month *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: