IKO-KNOT (PTY) LTD
Tel: 087 808 7288
235 Montana Street, Montana, Pretoria, 0159
Email: admin@iko-knot.co.za
Company Reg No: 2014/149951/07
Authorised Financial Service Provider -NCRCP2028
NCR Reg No. NCRCP2028
BUSINESS LOAN APPLICATION FORM
PERSAPPLICATION
BRANCH NAME
AGENT CODE
APPLICANT DETAILS
1
APPLICANT DETAILS
TITLE
FIRST NAME
NAMES ALSO KNOWN AS (AKA)
SURNAME
MAIDEN NAME
GENDER
MALE
FEMALE
ID NUMBER
HOME TELEPHONE
CELL NUMBER
EMAIL ADDRESS
PHYSICAL ADDRESS
POSTAL ADDRESS
SUBURB
SUBURB
CITY/TOWN
CITY/TOWN
PROVINCE
PROVINCE
CODE
CODE
RESIDENTIAL STATUS
RENT
OWN
PERIOD AT PRESENT ADDRESS Y
MARITAL STATUS
Y
HOSTEL
LIVE WITH PARENTS
OTHER
M M
SINGLE
LIVING TOGETHER
HAVE YOU APPLIED FOR
OR ARE YOU UNDER:
COMPANY PROVIDED
DEBT REVIEW Y
2
MARRIED
MARRIED
Out of community
of property
In community
of property
SEPARATED
N
CUSTOMARY
MARRIAGE
WIDOWED
DIVORCED
NUMBER OF DEPENDENTS
ADMINISTRATION Y
N
SEQUESTRATION Y
N
EMPLOYMENT START DATE Y
Y
EMPLOYMENT DETAILS
NAME OF EMPLOYER
BRANCH
OCCUPATION
EMPLOYMENT STATUS
SALARY PAID
WORK TELEPHONE
PERMANENT
MONTHLY
PART TIME
ON DATE
WEEKLY
CONTRACT WORKER
ON DAY M
T W T
Y
Y
/
M M
/
D
D
SELF EMPLOYED
F
PAYROLL TEL NO
EMPLOYER PHYSICAL ADDRESS
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CITY/TOWN
PROVINCE
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IKO-KNOT (PTY) LTD
Tel: 087 808 7288
235 Montana Street, Montana, Pretoria, 0159
Email: admin@iko-knot.co.za
Company Reg No: 2014/149951/07
Authorised Financial Service Provider -NCRCP2028
NCR Reg No. NCRCP2028
3
BANKING DETAILS
NAME OF ACCOUNT HOLDER
BANK NAME
BRANCH NAME
BRANCH CODE
ACCOUNT NUMBER
ACCOUNT TYPE
CHEQUE
SAVINGS
4
TITLE
OTHER (SPECIFY)
SPOUSE/ PARTNER DETAILS
INITIALS
SURNAME
FIRST NAMES
DATE OF BIRTH Y
Y
Y
Y
/
M M
/
D
D
HOME NUMBER
WORK TELEPHONE
CELL NUMBER
EMAIL ADDRESS
NEXT OF KIN / RELATIVE / FRIEND – NOT RESIDING WITH YOU
5
TITLE
INITIALS
SURNAME
FIRST NAMES
RELATIONSHIP
CELL NUMBER
HOME TELEPHONE
WORK TEL
EMAIL ADDRESS
6
INCOME & EXPENSES
.
R
NET SALARY (AS SHOWN ON PAYSLIP)
A
CALCULATE ALL YOUR LIVING EXPENSES EXCLUDING LOANS, EXAMPLE: FOOD, RENT, TRAVEL, SCHOOL FEES, ETC.
7
LIVING EXPENSES
R
.
B
TOTAL OF MONTHLY REPAYMENTS
R
.
C
BAYPORT PRODUCT OFFERINGS (PLEASE COMPLETE THE RELEVANT BLOCKS)
7.1
LOAN APPLICATION
.
AMOUNT REQUESTED R
HOW WOULD YOU LIKE TO RECEIVE YOUR STATEMENT?
LANGUAGE PREFERENCE
ENGLISH
AFRIKAANS
E-MAIL
PRINTABLE WEB PAGE BY SMS/MMS
SOUTHERN SOTHO
ZULU
IKO-KNOT automatically sends all communication relating to loans in English. If you wish communication in respect of loan
products
to be in Afrikaans, Zulu or South Sotho, please make a selection above or call Client Service on 087 808 7288 to specify your choice.
No agent is permitted to give you advice in respect of any insurance products. If you require advice on any insurance products or insurance related matters,
please contact IKO-KNOT 087 808 7288.
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7.2
PRODUCT OR MERCHANT APPLICATION
ARE YOU INTERESTED IN A MERCHANT/PRODUCT PACKAGE FROM IKO-KNOT?YES
NO
WORK DELIVERY ADDRESS
SUBURB
CITY/TOWN
PROVINCE
CODE
PREFERRED DELIVERY TIME
:
TO
:
AM
PM
PREFERRED PHONE PACKAGE
FOR OFFICE USE ONLY
PACKAGE NUMBER
7.3
INSURANCE COVER
Please note that IKO-KNOT is now able to provide an exciting range of insurance products for you and your family. Please ask your agent to
share the IKO-KNOT Brochure/s with you.
Having seen the brochure for Funeral Insurance Cover which will provide cover for you, your partner, up to 5 children and
your parents, are you interested in taking up the Funeral Insurance Cover?
Y
N
Having seen the brochure for Personal Accident Insurance Cover which will provide cover for you, your partner and
up to 5 children, are you interested in taking up the Personal Accident Insurance cover?
Y
N
8
AGENT DISCLOSURES
COMPULSORY FOR AGENT TO COMPLETE IF CUSTOMER APPLIES FOR PRODUCT/MERCHANT PACKAGE OR INSURANCE
PRODUCTS
THE AGENT WHO PRESENTS THIS APPLICATION TO YOU IS AN INTERMEDIARY UNDER THE CONSUMER PROTECTION ACT. THE DETAILS AND
DISCLOSURES OF THE INTERMEDIARY/AGENT AS REQUIRED BY THE CONSUMER PROTECTION ACT AND OTHER APPLICABLE LAWS ARE LISTED BELOW.
FULL NAME OF AGENT
ID NUMBER OF AGENT
PHYSICAL WORK ADDRESS OF AGENT
POSTAL ADDRESS OF AGENT
SUBURB
SUBURB
CITY/TOWN
CITY/TOWN
PROVINCE
PROVINCE
CODE
CODE
HOME TELEPHONE
CELL NUMBER
EMAIL ADDRESS
SERVICES
The Agent has been appointed by IKO-KNOT to:
1. market merchant purchase and Investment Products on behalf of IKO-KNOT; and
2. market and originate loan products on behalf of IKO-KNOT;
3. originate applications for funeral insurance products (but agents are not mandated to provide advice in respect of funeral insurance
products).
FEES
There are no fees payable by you to the agent. Please do not pay any money to the agent for any services rendered or in respect of
any agreement with IKO-KNOT or for any other reason whatsoever.
COSTS
The agent is not entitled to recover any costs from you.
CONTACT
1.
2.
3.
COMMISSION ON CELLULAR PACKAGE
PRODUCTS
IKO-KNOT pays a commission to the agent on services or products sold.
COMMISSION ON FUNERAL
INSURANCE PRODUCTS
IKO-KNOT pays a commission to the agent.
CODES OF CONDUCT
The agent must comply with IKO-KNOT internal code of conduct and policies which apply to agents and with the terms of its
mandate from IKO-KNOT.
Once you have completed this application, the agent will not contact you.
IKO-KNOT will contact you telephonically to proceed with the transaction since the agent will have completed his mandate.
All telephone calls are electronically recorded for purposes of quality and record keeping.
The agent confirms that he / she has never been found guilty of any offence involving dishonesty, been placed under sequestration, liquidation or judicial management.
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8
MANDATE
I, herewith instruct IKO-KNOT to load a debit order onto the above mentioned bank account to debit the once off fee. I agree that the debit order be loaded
onto my bank account as soon as IKO-KNOT has received feedback on my application. Once IKO-KNOT has submitted my personal loan application to the
Brokers (depending on service required) or have loaded it onto their systems I will receive an email entitled: Feedback. And be in contact directly with the brokers
/ service providers. I understand and agree to pay a once off fee of R356.96 for services rendered and I fully understand that the fee I non-refundable, and that
the fees do not guarantee that a loan will be granted in my favor. The fee is payable on my following salary date.
Initial:_____________
Date to Debit:____________
9
DECLARATIONS
By completing and signing this application, I, the undersigned applicant, understand and agree that –
1. IKO-KNOT and (IKO-KNOT successors) may transfer its rights under this application to any third party which it may, in its sole discretion, decide to transfer its rights to. Any
such third party or any person interested in this application or any agreement resulting from this application will be entitled to rely on the correctness and accuracy of the
information I have set out in this application and any supporting documents which I may provide;
2.
IKO-KNOT will decide, in its sole discretion, to either approve or decline this application. If IKO-KNOT refuses to grant a loan, I am entitled to ask IKO-KNOT for its reasons in
refusing to grant me credit;
3. IKO-KNOT has the right to verify all information provided by me in this application form and I consent to IKO-KNOT conducting all such verification checks (including, without
limitation, credit bureau checks, fraud database checks, employment checks and the like) to assess my application and to obtain any information (including medical related
information) it may require from third parties and I consent to such third parties giving IKO-KNOT the required information;
4. I consent to IKO-KNOT furnishing information about me to IKO-KNOT Management which relates to or has a bearing on any suspected or proven fraudulent activity.
IKO-KNOT reserves the right to refer any instance of suspected or proven fraud to the SAFPS and/or SAPS and, where possible, will actively seek to prosecute those
responsible;
5.
The information provided to IKO-KNOT and collected by IKO-KNOT in this application and the verifying supporting documentation may be used by IKO-KNOT and companies
associated with or appointed by IKO-KNOT for the purpose of assisting with this application and/or the conclusion of an agreement with IKO-KNOT;
6.
Various third party service providers who are not employees of IKO-KNOT render services to IKO-KNOT and/or Insurance Company and may need access to my personal
information in order to render those services. By signing this application form, I hereby consent to IKO-KNOT disclosing and/or transferring and/or hosting
my personal information (including any medical-related information) to or with third parties appointed by IKO-KNOT to render services to it as well as to any third party who may
acquire an interest (such as ownership, security interest or the like) in the product offering agreements concerned;
7. This application and all decisions and required documents will form part of any agreement/s signed with IKO-KNOT and shall be read together with that agreement/s as one document;
8. If I have withheld information or provided false information when completing this application, I will not qualify to conclude an agreement for any IKO-KNOT product and if IKO-KNOT
finds this out at a later stage, it will be entitled to cancel the agreement, without penalty, on the basis thereof;
9. In respect of the IKO-KNOT Personal Funeral Insurance Policy and/or the IKO-KNOT Personal Accident Insurance Policy that I may take out with IKO-KNOT, the following shall
apply –
•
I confirm that the agent only provided me with facts about the policy and did not give me any advice and I am free to contact a financial advisor if I want advice;
•
I decided to apply for the policy out of my own free will;
•
I have 30 days from the date that I receive the policy wording to decide whether to keep the policy. If I inform IKO-KNOT in writing that I do not want the policy, then IKOKNOT will pay back any premiums that I paid during such 30 day period;
•
I understand that if IKO-KNOT does not receive the amount I owe them every month, my policy will stop. I will not get any benefit and IKO-KNOT will not pay back any money I
have paid.
•
I understand that an insured person may not be covered for more than R150 000 for funeral benefits , even if they are covered under more than one IKO-KNOT funeral
policy. I understand that R150 000 at most will be paid out if the insured person dies; and
•
I understand that IKO-KNOT will receive commission (for rendering intermediary services) of 3.25% plus VAT of the total premiums paid under the policy and a binder fee of
R7.00 per policy per month. I acknowledge that a related party of IKO-KNOT has a financial interest in a related party of IMB which enables IKO-KNOT’s related party to
benefit from the overall performance of the funeral and personal accident insurance schemes.
10
MARKETING
MAY IKO-KNOT OR A THIRD
PARTY APPOINTED BY US FOR
THIS PURPOSE CONTACT YOU FOR
PURPOSES OF MARKETING OUR
PRODUCTS AND SERVICES VIA ALL
MEDIA?
Y
N
12
If you have ticked the “yes” box, you consent to IKO-KNOT giving your personal information (which IKO-KNOT collects
and processes as part of this application) to our marketing team, including our employees, third party service
providers, subcontractors and agents (including, without limitation, origination agents) for purposes of contacting you
regarding IKO-KNOT products and services or related products and services. This contact may include
telemarketing, SMS and email and/or any other means.
SIGNATURE
I, the undersigned, declare that all information which has been completed on this form is true and correct and that all information provided about my income
and expenses is a true reflection of my current financial position and if there are any other material facts that I believe could reasonably be relevant, I have
made those material facts known.
X
APPLICANT SIGNATURE
DATE
NAME IN PRINT
PLACE
THIS APPLICATION MAY TAKE UP TO 5 WORKING DAYS TO PROCES
13
IKO-KNOT Client Service Telephone Number: 087 808 7288
Email: admin@iko-knot.co.za
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