APPLICATION FORM
INDIVIDUAL AND FAMILY INSURANCE PLAN
AGENT CODE
PRINCIPAL MEMBER
ID number
*
Enter your 13 Digit RSA Identity Number
Name
*
First Names
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
Limpopo
Mpumalanga
Northern Cape
Northwest
Western Cape
COVER OPTIONS
Cover Type
Burial Cover
Cash Only Cover
Policy Type
*
Single Member
Member & Spouce
Single Parent
Family
NOMINATED FAMILY DEPENDANTS (MAXIMUM ENTRY AGE 84)
Name Spouse
First Name
Last Name
ID Number Spouse
Enter your 13 Digit RSA Identity Number
Name Child 1
First Name
Last Name
ID Number Child 1
Enter your 13 Digit RSA Identity Number
Name Child 2
First Name
Last Name
ID Number Child 2
Enter your 13 Digit RSA Identity Number
Name Child 3
First Name
Last Name
ID Number Child 3
Enter your 13 Digit RSA Identity Number
Name Child 4
First Name
Last Name
ID Number Child 4
Enter your 13 Digit RSA Identity Number
Name Child 5
First Name
Last Name
ID Number Child 5
Enter your 13 Digit RSA Identity Number
Name Child 6
First Name
Last Name
ID Number Child 6
Enter your 13 Digit RSA Identity Number
BENEFICIARY
Name
First Name
Last Name
Relationship
ID No
Enter your 13 Digit RSA Identity Number
Phone Number
Please enter a valid phone number.
Format: 000 000-0000.
PREMIUM CHOICE
BURIAL COVER
Single Member
R 50.00 Mopane 65
R 110.00 Mopane 75
R 175.00 Mopane 85
R 60.00 Morula 65
R 135.00 Morula 75
R 235.00 Morula 85
R 80.00 Baobab 65
R 155.00 Baobab 75
R 275.00 Baobab 85
Member & Spouse
R 80.00 Mopane 65
R 185.00 Mopane 75
R 265.00 Mopane 85
R 95.00 Morula 65
R 200.00 Morula 75
R 275.00 Morula 85
R 115.00 Baobab 65
R 250.00 Baobab 75
R 370.00 Baobab 85
Single Parent (Incl. Up to 6 Children under 22 years)
R 60.00 Mopane 65
R 135.00 Mopane 75
R 225.00 Mopane 85
R 70.00 Morula 65
R 175.00 Morula 75
R 255.00 Morula 85
R 95.00 Baobab 65
R 190.00 Baobab 75
R 295.00 Baobab 85
Family Cover (Incl. Up to 6 Children under 22 years)
R 90.00 Mopane 65
R 210.00 Mopane 75
R 310.00 Mopane 85
R 105.00 Morula 65
R 225.00 Morula 75
R 315.00 Morula 85
R 130.00 Baobab 65
R 300.00 Baobab 75
R 425.00 Baobab 85
PREMIUM CHOICE
CASH ONLY COVER
Single Member
R 75 - R 12,500 (65)
R 145 - R 12,500 (75)
R 235 - R 12,500 (85)
R 85 - R 18,000 (65)
R 160 - R 18,000 (75)
R 310 - R 18,000 (85)
R 105 - R 20,000 (65)
R 195 - R 20,000 (75)
R 345 - R 20,000 (85)
R 120 - R 25,000 (65)
R 225 - R 25,000 (75)
R 400 - R 25,000 (85)
Member & Spouse
R 100 - R 12,500 (65)
R 230 - R 12,500 (75)
R 345 - R 12,500 (85)
R 130 - R 18,000 (65)
R 285 - R 18,000 (75)
R 410 - R 18,000 (85)
R 160 - R 20,000 (65)
R 310 - R 20,000 (75)
R 500 - R 20,000 (85)
R 175 - R 25,000 (65)
R 340 - R 25,000 (75)
R 590 - R 25,000 (85)
Single Parent (Incl. Up to 6 Children under 22 years)
R 85 - R 12,500 (65)
R 185 - R 12,500 (75)
R 280 - R 12,500 (85)
R 100 - R 18,000 (65)
R 200 - R 18,000 (75)
R 370 - R 18,000 (85)
R 120 - R 20,000 (65)
R 235 - R 20,000 (75)
R 415 - R 20,000 (85)
R 135 - R 25,000 (65)
R 265 - R 25,000 (75)
R 480 - R 25,000 (85)
Family Cover (Incl. Up to 6 Children under 22 years)
R 110 - R 12,500 (65)
R 265 - R 12,500 (75)
R 390 - R 12,500 (85)
R 145 - R 18,000 (65)
R 325 - R 18,000 (75)
R 480 - R 18,000 (85)
R 180 - R 20,000 (65)
R 360 - R 20,000 (75)
R 590 - R 20,000 (85)
R 200 - R 25,000 (65)
R 395 - R 25,000 (75)
R 690 - R 25,000 (85)
Joining Fee
*
R 250.00
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
PAYMENT OPTIONS
Select Preferred Option
*
CASH
EFT
DEBIT ORDER
DEBIT ORDER BANK DETAILS
Name
First Name
Last Name
Contact 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 Payment
Monthly Amount
Day of the Month
1st
7th
15th
25th
Month End
Main Member Signature
Date
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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