Dignity Group

FAMILY FUNERAL PLAN

1+9 Burial Plan

About you, the applicant
ID number Surname First names Tel no (W) Tel no (H) ( ( ) ) Title Ethnic group Marital status Cellular Fax ( ) Postal code Postal code Initials Black Single Gender Coloured Married Male Indian Divorced Female White Widowed
Ethnic group information only for statistical purposes

Residential address Postal address Do you require funeral cover for your immediate family?

Extended family you wish to include under your cover

Surname First names Relationship Date of birth d d m m y y d d m m y d d m m y d d m m y d d m m y d d m m y d d m m y d d m m y y y y y y y y y y y y y y y y y y y y y y y y y y Age Gender

1. 2. 3. 4. 5. 6. 7. 8. 9.
Particulars of benefits

d d m m y y

Family funeral plan

Plan A R5 000 R100.00

Plan B R10 000 R150.00

Plan C

Plan D

Plan E

Funeral plan option selected Deduction fee Total monthly premium

Plan

R R 3.50 R

Family 18 - 65 years Monthly premium

Your beneficiaries - who must receive the policy benefits

Surname Title Initials All assured lives will enjoy the same cover as chosen by main assured
1. 2.
I, the member under this policy, hereby nominate the above-mentioned persons/company as the beneficiary in terms of this policy, to receive all benefits payable under this policy. I hereby indemnify Assupol Life against any claim by myself or my relatives/estate in respect of the payment of the policy benefits to the nominated beneficiaries.

Identity number

Relationship

Benefit %

Signature of member

Date

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Payment of premiums by persal or another stop order

Premium deduction source Employment sector Payday Date of first deduction Method of payment Employee number/ temporary Persal number - For stop order payments. If client gets paid on the same date every month e.g. 25 or 27. Persal Another stop order Bank debit order

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Amount to be deducted

Premium deduction source and other particulars. I authorize my employer to deduct the premiums from my salary and to pay it to Assupol Life. If the premium changes for any reason in terms of policy or agreement between Assupol Life and the policyholder, Assupol Life likewise may deduct the premium from my salary. If payment cannot be done on the preferred payday of the month filled in above, it must be done on a day that is as close as possible to that day, determined by the employer. If the policy ends. I may cancel, amend or replace this authorisation by written notice to my employer. I accept that my employer must receive notice not later than 30 days before the month from which the cancellation, amendment or replacement is to apply. I have read, understand, and agree with the above payment authorisation. Signature of premium-payer Date

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Underwritten by

Life Limited

Assupol Life Ltd reg no 2010/025083/06 Authorised financial services & credit provider Head office 308 Brooks street, Menlo Park, Pretoria, 0081

Payment of premiums by bank debit order

Name of bank Account number Preferred date of deduction Branch Type of account Current Branch code Savings Transmission

I authorize Assupol Life to draw the premiums from my bank account. If the premium changes for any reason in terms of the policy or by agreement between Assupol Life and the policyholder, Assupol Life likewise may draw the changed premiums from my bank account. If payment cannot be done on the preferred payment date filled in below, it must be done on a day that is as close as possible to that day, determined by Assupol Life. If the policy ends, this authorization also ends. I may cancel, change or replace this authorization by written notice to Assupol. I accept that Assupol Life must receive the notice not later than 30 days before the month from which the cancellation, change or replacement is to apply Signature of premium-payer Date

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I, the applicant, declare

(1) You, Assupol Life, will consider my application according to your underwriting rules and practice. (2) If you approve my application, you will provide me with a summary of my policy. The summary will confirm the benefits and premiums of my policy, and other particulars. (3) My policy is issued in terms of a master policy that will apply to it. I may not take out more than one policy under this master policy. (4) My policy will come into existence, and begin to provide cover, at the beginning of the month in which you receive my first monthly premium. (5) I may cancel my policy. I must let you know in writing. If you receive my cancellation notice within 30 days after I have received my policy summary, or after it reasonably can be accepted that I should have received it, my policy will end. It will end when you receive my notice, and you will then pay back all premiums. (6) All information and documents that are necessary and sufficient to consider my application have been given to you. If information or documents have not been given to you, or is incorrect, you may decline claims under my policy, and I may forfeit premiums paid. (7) I am satisfied that I know and understand everything I need to know and understand about the insurance I apply for, that it meets my specific insurance needs, and that I will be able to pay the premiums.(8) Waiting periods will apply to my policy. (9) This form has been completed properly, everything in it is correct, and I understand and agree with everything. Companies in the Assupol group of companies may from time to time offer other products or services to me Signature of applicant Date [yes] [no]

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Declaration by intermediary
Surname Initials ID number

(1) I have not and will not give money or anything of value to the applicant or a person whose life is to be insurance as an inducement to take out the insurance, and I have not in any way misled the applicant or such other person about any aspect of the insurance. As far as I know no-one else has done or will do any of these things. (2) I have explained to the applicant the meaning and implications of replacing insurance, and I am fully aware of the possible detrimental consequences of replacing insurance. Signature of intermediary Intermediary code Date

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Underwritten by

Life Limited

Assupol Life Ltd reg no 2010/025083/06 Authorised financial services & credit provider Head office 308 Brooks street, Menlo Park, Pretoria, 0081