Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Product Selection
Checkers Discount Coupons
Up to R5000.00 discount coupons every month from all Checkers and Affiliate Stores
Checkers
*
Checkers Discount Coupons
Embedded Funeral Cover
From R 5000.00 to R 20 000.00 cover
Funeral Cover
*
Embedded Funeral Cover
Air Time And Data Discounts
Receive discounts on airtime and data on all networks
Data and Airtime Discounts
*
Included
Monthly And Annual Prize Draw
Automatic entry into the monthly R 5000.00 draw and then the annual R 50 000.00 draw. Terms and Conditions Apply.
Entry Into Monthly Draw And Annual Draw
*
Included
Monthly Premium
ONLY SELECT ONE
Single Member - Checkers/Funeral/Data/Draw/No Nkomo
Single Person - Age up to 65 years old - NO NKOMO
Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R140.00 pm
Checkers/ R10 000.00 Single Funeral/Airtime & Data Discount/Draw - R149.00 pm
Checkers/ R20000.00 Single Funeral/Airtime & Data Discount/Draw - R158.00 pm
Single Person - Age up to 65 to 75 years old - NO NKOMO
Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R148.00 pm
Checkers/ R10 000.00 Single Funeral/Airtime & Data Discount/Draw - R157.00 pm
Checkers/ R20000.00 Single Funeral/Airtime & Data Discount/Draw - R165.00 pm
Single Person - Age up to 75 to 85 years old - NO NKOMO
Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R201.00 pm
Single Member - Checkers/Funeral/Data/Draw/ Nkomo
Single Person - Age up to 65 years old - INCLUDING NKOMO
Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R148.00 pm
Checkers/ R10 000.00 Single Funeral/Airtime & Data Discount/Draw - R159.00 pm
Checkers/ R20000.00 Single Funeral/Airtime & Data Discount/Draw - R180.00 pm
Single Person - Age up to 65 to 75 years old - INCLUDING NKOMO
Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R157.00 pm
Checkers/ R10 000.00 Single Funeral/Airtime & Data Discount/Draw - R168.00 pm
Checkers/ R20000.00 Single Funeral/Airtime & Data Discount/Draw - R185.00 pm
Single Person - Age up to 75 to 85 years old - INCLUDING NKOMO
Checkers/ R5000.00 Single Funeral/Airtime & Data Discount/Draw - R250.00 pm
Family Cover - Checkers/Funeral/Data/Draw/No Nkomo
Family - Age up to 65 years old - NO NKOMO
Checkers/ R5000.00 Family Funeral/Airtime & Data Discount/Draw - R147.00 pm
Checkers/ R10 000.00 Family Funeral/Airtime & Data Discount/Draw - R159.00 pm
Checkers/ R20000.00 Family Funeral/Airtime & Data Discount/Draw - R170.00 pm
Family - Age 65 to 75 years old - NO NKOMO
Checkers/ R5000.00 Family Funeral/Airtime & Data Discount/Draw - R159.00 pm
Checkers/ R10 000.00 Family Funeral/Airtime & Data Discount/Draw - R168.00 pm
Checkers/ R20000.00 Family Funeral/Airtime & Data Discount/Draw - R204.00 pm
Family Cover - Checkers/Funeral/Data/Draw/Nkomo
Family - Age up to 65 years old - WITH NKOMO
Checkers/ R5000.00 Family Funeral/Airtime & Data Discount/Draw - R169.00 pm
Checkers/ R10 000.00 Family Funeral/Airtime & Data Discount/Draw - R177.00 pm
Checkers/ R20000.00 Family Funeral/Airtime & Data Discount/Draw - R186.00 pm
Family - Age 65 to 75 years old - WITH NKOMO
Checkers/ R5000.00 Family Funeral/Airtime & Data Discount/Draw - R175.00 pm
Checkers/ R10 000.00 Family Funeral/Airtime & Data Discount/Draw - R188.00 pm
Checkers/ R20000.00 Family Funeral/Airtime & Data Discount/Draw - R199.00 pm
Authority To Debit
Account In The Name Of
*
First Name
Last Name
Account type
*
Cheque
Savings
Transmission
Other
Account Number
Who Do You Bank With
*
ABSA Bank: 632 005
African Bank: 430 000
Bank of Athens: 410 506
Bidvest Bank: 462 005
Capitec Bank: 470 010
Discovery Bank: 679 000
FNB: 250 655
Investec Private Bank: 580 105
Nedbank: 198 765
Old Mutual Bank: 462 005
Rand Merchant Bank: 261 251
RMB Private Bank: 222 026
SA Post Bank: 460 005
Standard Bank: 051 001
Standard Chartered Bank: 730 020
Tyme Bank: 678 910
Debit date
1st
15th
25th
Last day of the month
Start Date
-
Month
-
Day
Year
Date
Do you authorise Valueserv on behalf of Imali - Imali to issue and deliver payment instructions to your Banker for collection against your above-mentioned account at your Bank (or any other Bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement and commencing on the selected date and continuing until this Authority and Mandate is terminated by you by giving us notice in writing of not less than 20 ordinary working days, in writing. The individual payment instructions so authorised to be issued must be issued and delivered monthly. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the very next ordinary business day.
Yes client agreed
No client wants more info / does not agree
Agent Name
Submit
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