Mode of Payment
Bank Debit Order
Private Stop Order
Government Stop Order
Underwritten by NestLife Assurance
Easy Pay
Funeral Cover Application Form
PRODUCT NAME
(Please Tick√ 1 box):
Bronze R6K
PRODUCT NAME
(Please Tick√ 1 box):
Elite R21K
TYPE OF PLAN:
Silver R8.5K
Gold R10K
Elite Plus R30K
(Please Tick √ 1 box): Family
Platinum R13K
Exclusive R50K
Single Parent
Individual
MAIN MEMBER DETAILS
Inception Date:
1st of the following month of receipt of 1 st premium. Title:
Ms
Mrs
First Names:
Mr
Dr
Other:
Surname:
Date of Birth:
Passport/ID No.
Phone/Cell No:
Postal Address:
Fax No:
Home Address:
Email:
OTHER FAMILY MEMBER DETAILS (Spouse, Children Extended Children)
First Name
Capital Letters
Surname
Capital Letters
Date of Birth
DD/MM/YYY
ID No.
Passport No.
Beneficiary Name & Surname:
Relationship
ID / Passport No.
BANK ACCOUNT DETAILS : FOR MEMBERS WHO PAY THROUGH A BANK DEBIT ORDER
Bank
Branch Name
Acc Holder
1st
7th
Name
Account No.
Branch Code
Account Type
15 t h
20 t h
25 t h
Premium
:R
Additional Premium :R
Total Premium
:R
30/31 s t
Deduction
Date
:R299
Please tick(x) the applicable box above
I hereby grant Bataung Insurance Brokers NestLife permission to deb it m y bank account with the monthly premiums on the nominated date(current or arrears),
including amendments that may be made in terms or the contract and during the life of the contract. To avoid bank charges and possible cancellation of this
policy, I will ensure that there are sufficient funds in the bank account on the date of the deduction .
Bank Account Holder Signature :………………………………….Date(DD/MM/YYYY)………………………………
Declaration by Policyholder
I declare that the information provided above are to the best of my knowledge true, complete and correct. I acknowledge that I have requested the broker not to do a financial needs
analysis. I understand that completion of this form does not constitute an insurance contract until and policy contract is issued and the premium is successfully paid. Further that the
conditions and exclusions of the plan as set out in the quotation have been explained to me. I understand that a policy summary, including my personal details, chosen benefits and claims
procedures will be posted to me. I am aware of the waiting periods applicable to this policy. There is a limit of (1) one policy per Main Member under the policy. I am aware, and understand
that any non-disclosure or misrepresentation which is material to the determination of the risk by NestLife, may lead to the policy being declared null and void, in which case all premiums
paid, will be forfeited. I am certain that the product which I am applying for, meets my needs and that I have all the necessary information in order to make an informed decision in respect
of the purchase thereof. The policy shall come into force and effect on the inception date provided that the offer for insurance made by myself by way of this proposal form is
unconditionally accepted by NestLife.
Policyholder Signature:…………………………………..... Date: (DD/MM/YYYY)………………………………….
Fax: 086 523 8616
Email: info@bataunginsurance.com