MBALI ADMINISTRATIONS CC T/A
R F
oyal
uneral
S
ervices
VAT Reg No:4730228840
Reg No:2003/110183/23
Fsp no: 15781
HEAD OFFICE: Stand 09 Erasmus, Hebron
E-mailroyalfs@telkomsa.net  PO Box 911-776,Rosslyn 0200
012 706 0034 Cell: 082 2555 209 Fax: 012 706 0255/086 661 0255
Tel: 012 323 0080 Cell: 083 476 7479
Shop 14, Zone 1 Complex, GARANKUWA - Tel/ Fax: 012 703 8118
Stand 2, Lekgalaopeng Sec,SunCity rd, BAPONG
APPLICATION FORM
JOINING FEE
Ref No.
Type of Cover (For Office use only)
R150.00
Plan A
Plan B
Plan C
Plan A Single
Inception Date
Plan A Elite
Plan B Elite
Plan C Elite
Executive Plan
Pensioners Plan
Plan D
Plan E
PREMIUM AMOUNT
R
ADDITIONAL
R200.00
R250.00
FREE
R
TOTAL AMOUNT PAYABLE
R
There will be an annual increase on premiums
MEMBER DETAILS
TITLE
INITIALS
SURNAME
NAMES
Marital Status
ID
NO
Married
Single
Divorced
Other
Spouse Name and Surname
ID
NO
Residential Address
Postal
Code
Postal
Code
Postal Address
Tel No.
Cell No.
Fax No.
E-mail
Details of Family members to be covered
Name and Surname
ID No.
Relationship
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Extra R20.00 per member if more than 10 members in a plan
1.
2.
Payment (ROYAL FS ENCOURAGES MEMBERS TO USE THE BANK/CREDIT CARD DEBIT ORDER TO PROCESS PAYMENTS)
Cash
Bank Debit
Payment/Action Date for Debit order
7th
15th
Last Working day of the month
Signed at ____________________________________________ on the ____________ day of _____________________20_____
Our plans (only one plan per member can be chosen)
Amount
PLAN A






PLAN B







Coffin
Hearse and Family Car
Tent
50 Chairs
2 x Tables
2 x Pots

PREMIUM R60.00
PENSIONERS PLAN







PLANC










Coffin
Hearse and Family Car
Tent
50 Chairs
2 x Tables
2 x Pots
50 x copies of funeral
programmes
1 x Toilet
PREMIUM R100.00
PLAN A-SINGLE
* Coffin
*Hearse and family car
*Tent
*50 Chairs
*2X Tables
*2X Pots
Coffin
Hearse and Family Car
Tent
50 Chairs
2 x Tables
2 x Pots
Vegetables & groceries
PREMIUM R150.00
PLAN A ELITE








Coffin
Hearse and Family Car
Tent
70 Chairs
2 x Tables
2 x Pots
1 x Toilet
1 x Bus
1 x Gas Stove
100 x copies of funeral programmes
PLAN B ELITE






Coffin
Hearse and Family Car
Tent
50 Chairs
2 x Tables
2 x Pots
Vegetables
Groceries



Hearse and Family Car
Tent
70 Chairs
2 x Tables
2 x Pots
50 x copies of funeral
programmes
1 x Toilet
Vegetables & groceries
Matshidiso
PLAN C ELITE











Hearse and Family Car
Tent
70 Chairs
2 x Tables
2 x Pots
1 x Toilet
1 x Bus
1 x Gas Stove
150 x copies of funeral
programmes
Flowers
Matshidiso
PREMIUM R165.00
PREMIUM R100.00
EXECUTIVE PLAN
PREMIUM R175.00
PREMIUM R275.00
PLAN D AND PLAN E

















Casket
Hearse
Family car
Tent
100 x chairs
3 tables
2 pots
* 1 x Bus
* 1 x Toilet
* 150 x copies Funeral Programmes
* 1 x flower
* 1 x Name Board
* Matshidiso
PREMIUM R350.00
Coffin
Coffin spray
Hearse and Family Car
1 Bus
Tent
50 Chairs
1 x Tables
1 x Toilet
Funeral Programmes X 120
Refreshments
*Groceries
*Vegetables
* Meat
PREMIUMS R170.00 AND R185.00
PLAN A- SINGLE
ADDITIONAL PREMIUMS FOR EXTENDED
ALL THE BENEFITS IN PLAN A PREMIUM
Between 18 - 30years
:R60.00
Between 31- 50 years
:R90.00
Between 51 - 64 years
:R120.00
Between 65- 74 years
:R150.00
Over 75 years
:R175.00
OWN CHILDREN
Unmarried children between 21 - 30 years
Unmarried children over 31 years
Married Children/ in laws
PARENTS ( IN LAWS)
Under 40 years7
Between 41 - 74 years
Between 75 - 84 years
ALL PLANS INCLUDE THE FOLLOWING
 STORAGE
 GRAVEYARD EQUIPMENT
1. MATSHIDISO
PLAN B ELITE
Family to be covered
Cover
Member
Spouse
Children over 21yrs
Children between 14- 20yrs
Children between 1- 13yrs
Stillborn – 11 months
Extended members
Children over 21yrs
Children between 14- 20yrs
Children between 1- 13yrs
R2000.00
R2000.00
R1500.00
R1000.00
R750.00
R500.00
R1 000.00
R 550.00
R 370.00
BROTHERS,SISTERS, NEPHEWS & NIECES
20 years and below
: R 10.00
Between 21- 30 years
; R15.00
Between 31- 50 years
; R25.00
Between 51- 60 years
; R45.00
Between 61- 84 years
; R80.00
UNCLES,AUNTS & GRANDPARENTS
Under 35 years
;R25.00
Between 36- 45 years
;R40.00
Between 46-65 years
;R75.00
Between 66 – 84 years
;R95.00
:R10.00
:R20.00
:R25.00
:R20.00
:R35.00
:R80.00
PLAN C ELITE
Family to be covered
Member
Spouse
Children over 21yrs
Children between 14 – 20yrs
Children between 1 -13yrs
Stillborn – 11 months
Extended members/ (R45.00)
Children over 21yrs
Children between 14- 20yrs
Children between 1- 13yrs
Cover
R3500.00
R3500.00
R2000.00
R1500.00
R800.00
R500.00
R1 000.00
R 650.00
R 470.00
EXECUTIVE PLAN
Family to be covered
Member
Spouse
Children over 21yrs
Children between 14 -20yrs
Children between 1 -13yrs
Stillborn – 11months
Matshidiso R55.00
Children over 21yrs
Children between 14- 20yrs
Children between 1- 13yrs
Cover
R5000.00
R5000.00
R2500.00
R2000.00
R1000.00
R750.00
R1 000.00
R 750.00
R 550.00
NO MATSHIDISO FOR PERSONS OVER 84 years
2. VEGETABLES & GROCERIES
VEGETABLES
1 X BAG CABBAGE
1 X BAG POTATOES
1 X BOX TOMATOES
1 X BAG BEETROOT
1 X BAG CARROTS
1 X BAG ONIONS
GROCERIES
1 x 12,5 Mealie meal
1 x 10 kg Cake flour
1 x 10 kg Sugar
1x 1kg Milk Powder
1 x 5 litres Cooking Oil
1 x box Teabags
1 x 10 kg Mabele
MEAT
10 kg Mala Mogodu
2kg X 6 Braai packs
5kg X5 Sew beef
( The meat listed above only applies to
Plan D and Plan E)
3. CATERING
WE ONLY OFFER
Matsogo
Monthly premium
4. CASHBACK PLAN
R175.00
10% of your 3 years premium
IF NO CLAIM IN THREE YEARS YOU QUALIFY FOR 10% OF YOUR 3YRS PREMIUM
5.TOMBSTONE OFFER after 2 years
ROYAL FUNERALS is giving its members a free TOMBSTONE as a token of appreciation for their loyal support. For a
member to qualify for this incredible offer you have to:
1. Your premiums has to be up to date for 2 consecutive years (A CLAIM FREE 2 YEARS)
2. You should make sure that premiums are paid every month.
3. No probations between the 2 years
I Confirm that I have read all the contents in this page and I understand everything. Everything has been explained to me and agree with the contents on this page.
Initials and surname of Policy holder/ Premium Payer: ___________________________________________________
Signature of Policy holder/ Premium Payer :_________________________________________________
Date :___________________________________
POLICY TERMS AND CONDITIONS
1. All the information supplied by member to the Royal Funeral Service will form the basis of the contract with us (Royal Funeral Services), only persons mentioned in this forms with identity
documents copies will be covered under the contract between two parties. Member or dependants without identity document/birth certificates will not be covered. NO AFFIDAVITS WILL BE
ENTERTAINED. We reserve the right to alter the contributions, benefits and any other conditions contained in the policy at any given time, with a three month written notice to you. The relationship
between Royal Funeral Services and member is strictly based on society operation.
2. Waiting Period FOR ALL PLANS
2.1 Waiting period is calculated from the date you start to pay your first monthly premium ( The first payment after registration fee will be your first month of probation) The date which appears on
this form
PLAN A,B,C Main member, spouse and own children under 21 years
:
(03) three months
PENSIONERS PLANMain member, spouse and own children under 21 years
:
(03) three months
Single members at and under 65 years
:
(06) six months
Single members over 65 years
:
(12) twelve months
Children over 21years and extended family members
:
(06) six months
Names and ID copies provided after inception date
:
(06) six months
Member who skips or owes a payment (ELITE PLAN A,B,C)
:
(06) six months
Member who skips or owes a payment (EXECUTIVE PLAN)
:
(06) six months
Upgrading a plan (e.g.. From plan A to plan C)
:
(06) six months
Upgrading a plan (e.g.. From plan A to plan ELITE PLANS)
:
(06) six months
Where death occurs as a result of suicide
:
(24) twenty four months
ELITE PLAN A,B,C and EXECUTIVE PLAN
:
(6) six months
PLAN D AND E
:
(6) six months
CATERING
:
(6) six months
Unnatural deaths (MVA, gunshots etc) will be covered one month after the receipt of the first premium
3. Premium Payments
*Premiums are payable on the date you choose (preferably the 7th, 15th or last day of a month)
*Members owing their accounts for a period of two months will be fined.
*Members who owe two months on Plan A, Plan B, Plan C and Pensioners plan will pay the amount of R3000.00 before burial can be conducted.
*Members who owe two months on Plan A- Elite, Plan B- Elite, Plan C- Elite, Plan D and Plan E will pay the amount of R4000.00 before burial can be conducted
*Members owing two months on the executive plan will have to pay R5000.00 before a burial can be conducted.
*Member owing three months on all packages will have to conduct their burial on CASH basis because they would have forfeited their benefits after three months without paying.
*A person owing three months without any deaths, will incur a three months’ probation. A person owing from four months will have a six months’ probation.
*Members paying for Plan A, Plan B and Plan C will have to pay the full three months to qualify for burial. A client paying for Plan D and Plan E will have to pay the full six months before
qualifying for burial.
3.2 ELITE PLAN A,B,C and EXECUTIVE PLAN
Premiums are payable on the date chosen each month
If premiums are not paid by the chosen date of the next month the policy will lapse. Should the policy lapse as a result of late payments of premiums and the reinstated, all waiting periods will apply
accordingly from reinstatement date. There will be no refund of premiums on withdrawal, death of a member or cancellation of policy.
Royal Funeral Service cannot be held responsible if the member does not pay premiums
CANCELLATION OF MEMBERSHIP IS NOT REFUNDABLE
4. Cancellation of policy/ lost membership book/ lost policy documents
If a member decides to cancel the membership they shall not be entitled to any form of REFUND
Lost membership book/ policy documents are chargeable and paid upon before re-issue
5. Premium payers consent
As a member I hereby understand that should a payment not be made for some reason and my monthly premium not paid to Royal Funeral Service my benefits shall be withdrawn and premium are
wholly irrecoverable
6. Restriction of membership
No individual may apply for membership of more than one contract. In the event of death only one claim shall be made
7. Age at entry
A member should be 18 years and older to apply
8. Acceptance
Only a principal member, spouse and children under 25 years will be covered under the basic plan. Any other members will covered as extended family members and will have to be paid for an extra
amount depending on age and relationship.( These rule does not apply for Plan D and Plan E since there is no age restriction)
9. Claim Procedure for plan B & C ELITE and EXECUTIVE PLAN
Documents needed are certified
(i) ID Copy of deceased
(ii) ID Copy of claimant/chosen beneficiary
(iii) Membership Book
(iv) Membership Certificate/card
(v) Death Certificate
(vi) BI 1663/
(vii)Confirmation Letter from the undertaker if Royal Funeral Service does not
render this service
(vii). No affidavits will be entertained
10.Cash Back Plan
A cash back of 10% of total number of premiums of three years is offered only if in those three years a member has not claimed or Royal Funeral Service has not rendered any service to them.
11. Funeral Fund/ Matshidiso
Matshidiso are provided only if you contribute to this fund and only in case of a valid claim.
Matshidiso can be offered even if Royal Funeral Service does not render a funeral service, provided all the necessary documents (see 9) are provided
A payout is paid within 48 hours after all documents are received
12. Service Details (Plans A, B and C)
12. 1 Service in a radius 80km consists of above mentioned benefits and Service exceeding 80km only hearse, coffin, graveyard equipment will be provided and extra kilometers will be charged.
12. 2 Tent, chairs, tables, pots, gas stove, toilet, and other accessories are only offered in a radius of 80km.
12. 3 Bus is only offered in a radius of 40km (from home to cemetery) and extra kilometers will be charged.
12. 4 Service for the main member, spouse, children over 5 years and extended family members who are over 5 years consists of the above mentioned ( Plan (A, B or C) depending on the chosen
plan).
12. 5 Children between age of stillborn and 5 years only coffin and hearse will be provided.
12. 6 Royal Funeral Services will remove the deceased from home/government mortuary in a radius of 40km for free.
12. 7 Member or family will be responsible for any removal fees/charges from other private/government mortuary.
12. 8 Member or family will be responsible for doctor's/ grave fees.
12. 9 Member or family will be responsible for extra charges for an oversized or upgraded coffin.
12. 10 Catering is only provided for main member, spouse and children over 21 years and only in a radius of 80km.
13. Special Declaration
In case where the service of Royal Funeral Service is not required, the following will apply
13.1 the service cannot be exchanged for cash being paid to the member or the family, unless a member is paying a funeral fund policy.
13.2 accessories such as tents, chairs, pots etc shall not be made available.
13.3 no replacements will be made unless paid for,
13.4 overtime shall be charged accordingly, that is if the family decides to bury on SUNDAY and PUBLIC holiday.
14. Declaration on Debit orders
I declare and agree that upon signing a debit order agreement I cannot cancel it in anyway without prior three months written notice to Royal Funeral Services. Fees incurred due to me failing to
honour this declaration will be liable to me. I also agree that all fees incurred due to RD (Refer to Drawer) will be liable to me, including the unblocking of my account after two failed debit orders.
15. Declaration of the policy holder
I ______________________________________________________________ of ID No. ___________________________
declare that I have read and understood the terms and conditions laid by ROYAL FUNERAL SERVICES/ I declare that everything has be explained to me and I
understood everything and agree with the terms and conditions and will abide by them. I therefore state that all the information provided on this form by me is correct and
will not hold Royal Funeral Service responsible for the mistakes done by me.
Signed at _______________________________________ on the _______ day of ____________________ 20 _
Signature of Policy Holder _____________________________________________________________________________
Royal Funeral Services/ Agent name ___________________________________ Agent Number _____________________