Full Names: Surname: Initials: Date of birth: ID Number: Gender: Select Male Female Cellphone Number: Alternative Contact Number: E-mail address:

Main Member Details Personal

Address Line 1 Address Line 2 Surburb Town/City Postal Code

Preferred Plan

Plan Selected Select Plan Plan A R95 Plan B R150 Plan C R250 Office to receive future payments Select Office Ixopo Main Branch Greytown Branch Ixopo Sub Branch Umzimkhulu Branch Pietermaritzburg Branch Harding Branch Matatiele Branch Kokstad Branch

Dependants Information

Name Surname Initials Date Of Birth ID Number Gender Relationship with Main Member Dependent 1: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 2: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 3: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 4: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 5: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 6: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 7: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 8: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 9: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 10: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 11: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 12: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 13: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary Dependent 14: Select Male Female Select Sister Brother Child Mother Father Cousin Uncle Nephew Niece Spouse Non-Paying Beneficiary

Beneficiary Information

Name Surname Contact Number ID Number Beneficiary:

Terms and Conditions:

All new policies are subject to a 3 months waiting period. Should your policy lapse (due to non-payment for 3 or more months), the 3 months waiting period will apply.

I agree to all terms and conditions of this product and I also understand that I will not be able to claim within the waiting period as stipulated above.