NEW APOSTOLIC CHURCH
Cnr Healy & Van Buuren Road
Bedfordview, 2008
P O Box 1003, Bedfordview 2008
Tel: +27 11 622 3811
Fax: +27 86 688 0871
E-mail: burialclaims@nac-sea.org.za
NAC Funeral Plan
(Principal and Family Dependant Nomination Form for Existing Policies)
MAIN MEMBER DETAILS (block letters)
CONGREGATION:
FIRST NAMES
DATE OF BIRTH
TEL. (H.)
EMAIL ADDRESS
IDENTITY NO.
TEL. (W.)
SURNAME
CELL NO.
STREET ADDRESS
POSTAL CODE
POSTAL ADDRESS
NACSEA MEMBER NUMBER
DEPENDANTS
DETAILS:
SPOUSE
POSTAL CODE
BURIAL OPTION
MEMBER NO FULL NAMES & SURNAME
SEX
DATE OF BIRTH OR ID. NO.
CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5
NOMINATED BENEFICIARY
On my death I nominate the following person to receive the proceeds of any benefit payable in terms of this policy,
Or to authorise and finalise my funeral arrangements.
INITIALS & SURNAME
RELATIONSHIP
CONTACT NUMBERS
Declaration by Applicant
I, the undersigned, hereby declare and agree to the following terms & conditions:

The New Apostolic Church requires details of my Spouse and dependent Children within (1) one month of the respective dependant
becoming eligible for cover. Failure to submit could result in delays or repudiation at claim stage.

I am aware that I must inform the New Apostolic Church in writing within the specific time of any births of eligible children in order that they
may be covered.

All the information in this form as supplied in connection with my policy is true and correct and will form the basis of my policy.

I understand that any misrepresentation or false information can lead to the cancellation of my policy benefits, in which case all premiums
paid by me will be forfeited.
POLICY HOLDER’S SIGNATURE
DATE
ASSISTANT NAME