Policy No:
Application for Membership: Family Cover: Age 14- 65; Extended Family1 to 74 years
POLICY DETAILS
AGENT CODE: ___________________________ AGENT NAME : ___________________________________________________
MEMBER NO: _________________________________ ENTRY DATE: _________________ COVER DATE: ___________________
COVER CHOICE:
FUNERAL PLAN @ R18000
R69
PER EXTENDED MEMBER
(Age 01 - 74 years) @ R7500
R35
TOTAL PREMIUM =
MEMBER DETAILS
Surname: ______________________________________ First Names: _______________________________________
ID Number: _______________________________D.O.B: __________________ Tel No:_______________________
(Date of Birth)
Address: __________________________________________________________Code:________________________
SPOUSE DETAILS – If a Common Law spouse, please indicate by ticking the box
Surname: _______________________________________ First Names: ______________________________________
ID Number: __________________________________ D.O.B: _______________ Tel No: ________________________
(Date of Birth)
CHILDREN DETAILS
1.
____________________________________________________________________ D.O.B. ____________________________
2.
____________________________________________________________________ D.O.B. ____________________________
3.
____________________________________________________________________ D.O.B. ____________________________
4.
____________________________________________________________________ D.O.B. ____________________________
5.
____________________________________________________________________ D.O.B. ____________________________
6.
_____________________________________________________________________ DOB. _____________________________
EXTENDED MEMBER DETAILS
7.
____________________________________________________________________ D.O.B. ____________________________
8.
____________________________________________________________________ D.O.B. ____________________________
9.
____________________________________________________________________ D.O.B. ____________________________
(Date of Birth)
BENEFICIARY
Name/Surname: _______________________________________ ID Number: __________________________________
DECLARATION
I accept that if I provide false information, the policy can be cancelled. I accept the conditions of the policy and that cover will commence after THREE
CALENDAR MONTHS FOR IMMEDIATE FAMILY AND SIX MONTHS FOR ALL EXTENDED FAMILY MEMBERS. I accept that I am hereby curtailing
my dependants’ and my rights of privacy, but for risk, claim and benefit assessment, I irrevocably authorise African Unity Insurance to obtain
information from any Doctor, Medical Facility or other instance, at any time (even after my death). I declare that my family and I are in good health and
that none of us have an illness that may lead to an early death.
Signature of Main Member: __________________________________________________ Date: ________________________________________
I declare that I have seen the main member and that he/she is in good health
Printed name of AGENT / Representative ____________________________________________________ Date:______________________________
RULES OF THE SCHEME
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
This is a Voluntary Scheme and premiums are payable monthly in advance on or before the 1st of each month
Members who are 14 years or older may participate in the scheme.
No restrictions are placed on the size of a family but the insured lives will be limited to those declared on the application form
Members who are not legally married but who are living together as a family can still enjoy family benefits provided that all relevant particulars are
declared on the application form.
Unmarried children under the age of 21 are covered. Cover is extended up to, but not including age 26 if the child is an unmarried full time student.
Cover for physically or mentally disabled children are subject to the conditions contained in the Master Policy.
Cover for a member is subject to a six (6) calendar month waiting period as stipulated in the Master Policy.
Immediate cover is granted for accidental death after the first Premium is received by the Underwriter.
A one (1) calendar month waiting period will apply in respect of children under the age of 14 years.
Cover under the scheme will cease in respect of a particular member when premiums are not paid on time (see point 1. above) and received by
African Unity Insurance.
If a members’ cover should cease and the member applies to rejoin the scheme at a later stage, the same conditions as for new membership will
apply.
Cover under the scheme is provided for on a month-to-month basis. No reserves are built up under the scheme, therefore premiums are payable
lifelong and there are no surrender values when cover ceases.
Premiums under the scheme are not guaranteed and can be adjusted by the insurer at any stage.
If a member increases his/her cover under the scheme, the increased cover amount will be subject to the relevant waiting period of 6 Months,
before the full cover commences.
Membership under the scheme can only commence on the 1st day of a month.
An application for membership, together with the relevant premium, which is received during a month, will, if accepted, only be admitted as a
member of the scheme from the 1st day of the month following receipt of the application form and first premium. Cover will only commence after the
stipulated waiting period has expired.
Membership for new applicants will be restricted to a maximum entry age of 65 years for the main members and 75 years for any extended family
member at commencement.
Only claims submitted within three (3) months of the date of the death will be considered for payment.
No claim will be honoured if premiums are in arrears or short paid.
Claims for common-law spouses NOT declared on the initial application form will NOT be considered for payment in the event of death (Traditional
marriages – Labola – included).
NO claims in respect of grandchildren or foster children will be considered, unless proof of legal adoption has been supplied.
No benefit will be payable should a member or one of his/her dependants die as a result of any disease or illness of which the member or his/her
dependant was aware, or had received medical advice/treatment, prior to joining the scheme.
Death as a result of suicide is subjected to a 24 months waiting period.
DEBIT ORDER INSTRUCTION
Details of my/our bank account are as follows:
NAME OF ACCOUNT HOLDER
BANK
ACCOUNT NUMBER
BRANCH NUMBER
TYPE OF ACCOUNT
I/We hereby authorise AFRICAN UNITY INSURANCE to draw against my/our account with the abovementioned bank (or any other bank or branch to
which I/we may transfer my/our account) the amount necessary for payment of the monthly premium due in respect of funeral insurance. All such
withdrawals from my/our bank account by you shall be treated as though they had been signed by me/us personally. Should my account fall in arrears,
I/we hereby authorise AFRICAN UNITY INSURANCE to increase my monthly premiums to recover the arrears within the contract period.
I/We understand that the withdrawals hereby authorised will be processed by computer through a system known as Bank serve or any other electronic
means and I also understand that details of each withdrawal will be printed on my bank statement on an accompanying voucher. I/We agree to pay any
bank charges relating to this debit order instruction.
I/We agree to pay any and all bank charges that relate to this debit order including, without derogating from the generality hereof, all lodgement, failure
and other costs that AFRICAN UNITY INSURANCE may incur.
This authority may be cancelled by me/us by giving you 30 (thirty) days notice in writing, sent by prepaid registered post, but I/we understand that I/we
shall not be entitled to any refund of amounts which you have withdrawn while the authority was in force if such amounts were legally owing to you.
Receipt of this instruction by you shall be regarded as receipt thereof by my/our bank (whichever it is or will be).
Signed at __________________________________________(place) ON______ day _______________month of 201__
Signature of Main Member/Client: ___________________________________
Date: __________________________
KPT is a “Juristic Representative of African Unity FSP 8447”