SAPU Funeral Application Form

SAPU Funeral Application Form
New Application/Transfer*
Scheme Option*
Shop Steward

First NameLast Name
Persal Number
APPLICATION FOR VOLUNTARY FUNERAL ASSURANCE WITH EXTENDED FAMILY BENEFITS

Personal Details
Full Name Of Main Member*

First NameLast Name
ID Number*
Cell Number*
Email*
example@example.com
SAPU Number
Postal Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
UMNGCWABO*
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouses Personal Details
Name

First NameLast Name
ID Number
UMNGCWABO
Principal Members Own Children's Details
Child Details
Total Premium
Extended Family Details
Total Premium
Income calculation benefits(six months)
Income continuation benefit after death of principle member for 6 months will be R10.90 per month for every R1,000

Benefit Per Month R1000 Premium R10.90Benefits Per Month R2000 Premium R21.80Benefit Per Month R3000 Premium R32.70Benefit Per Month R4000 Premium R43.60
Total Premium Details
Total Immediate Family Funeral Premium (Incl. Umngcabo / Beef / Inkomo Premium)*
Extended Family Premiums*
Income Continuation Premium (6 Months)*
Grand Total Premium*
Beneficiary Nomination

I hereby nominate the following person for any benefits due to be paid from the scheme in the event of my death
Name*

First NameLast Name
ID Number*
Relationship*
PREMIUM PAYMENT

PERSAL DEDUCTION AUTHORIZATION prefer that my premium be deducted by means of PERSAL. Should this deduction fail, I authorize Safrican Insurance Company to deduct my premium by means of Debit Order.
Name*

First NameLast Name
Rank
Station*
ID Number*
Persal Number*
Total Amount*
Date*

DayMonthYear
Date
Signature*
Date*

DayMonthYear
DateHourMinutesAM/PM Option
When selecting payment via Persal, please also complete the Debit Order section to be used only in case of limit exceed
Debit Order Authorization
Account Holder*

First NameLast Name
Bank Name*
Branch Code*
Branch name*
Account Number*
Account Type*
Start Date*

DayMonthYear
Date
Policy Payer's Signature*
Date*

DayMonthYear
DateHourMinutesAM/PM Option
Declaration
Principal Member's Signature*
Date*

DayMonthYear
DateHourMinutesAM/PM Option
Should be Empty:

SAPU Funeral Application Form

APPLICATION FOR VOLUNTARY FUNERAL ASSURANCE WITH EXTENDED FAMILY BENEFITS

Spouses Personal Details

Principal Members Own Children's Details

Extended Family Details

Income calculation benefits(six months)

Total Premium Details

Beneficiary Nomination

PREMIUM PAYMENT

Debit Order Authorization

Declaration