Khanyisa | New Leads

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SHOP STEWARDS DETAILS

Select Application Type :

Policy Number :

Select Scheme Option :

Premium R :

Application Date :

Inception Date :

Shop Steward : @foreach($ss as $contact) @endforeach

Station :

Region :

Province :

Cell Number :

Email :

Khanyisa Agent :

MAIN MEMBERS DETAILS

Region :

Station :

Surname :

Name :

ID Number :

Age :

Cell Number :

Work Number :

Email :

SAPU Number :

Residential Address :

Residential Address Postal Code :

Postal as residental:

Postal Address :

Postal Address Postal Code :

Inkomo :

Next Step

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PERSONAL DETAILS OF SPOUSE:

Surname :

First Name :

ID Number :

Too old

Premium R :

Inkomo :

PRINCIPAL MEMBER’S OWN CHILDREN DETAILS :

Name :	Surname :	ID Number :	Age :	Inkomo :	Preminum R :
	Doesn't match Main member	Not in age gap for Inkomo	Too old
	Doesn't match Main member Doesn't match Primary memeber	Not in age gap for Inkomo	Too old
	Doesn't match Main member	Not in age gap for Inkomo	Too old
	Doesn't match Main member	Not in age gap for Inkomo	Too old
	Doesn't match Main member	Not in age gap for Inkomo	Too old
	Doesn't match Main member	Not in age gap for Inkomo	Too old
TOTAL IMMEDIATE FAMILY PREMIUM :

WIDER CHILDREN’S DETAILS :

Name :	ID Number :	Premium R :
	Too old
	Too old
	Too old
	Too old
TOTAL WIDER CHILDREN PREMIUM :

EXTENDED FAMILY DETAILS :

Add new member

Name :	ID Number :	Age :	Repatriation:	Inkomo:	Cover Amount :	Cover Premium :	Repatriation Premium :	Inkomo Premium :	Total Prem :




TOTAL EXTENDED FAMILY PREMIUM :

Repatriation benefit for extended family members can be added @ R2.30 per member.

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INCOME CONTINUATION BENEFIT: (Six Months)

Income continuation benefit after death of principle member for 6 months @ R10.90 per month for every R1,000

BENEFIT PER MONTH	PREMIUM	SELECT
R 1,000	R10.90
R 2,000	R21.80
R 3,000	R32.70
R 4,000	R43.60

OPTIONAL BENEFITS:

OPTIONAL BENEFIT	COVER	PREMIUM	SELECT
Airtime	R 250	R 7.60
Car Hire	R 7,500	R 34.10

TOTAL PREMIUM CALCULATION

Total Immediate Family Funeral Premium + Inkomo / Beef / Inkomo Premium
Wider Children Premium
Extended Family Premium
Income Continuation Premium (6 Months)
Airtime Premium
Car Hire Premium
GRAND TOTAL PREMIUM

BENEFICIARY NOMINATION

I hereby nominate the following person for any benefits due to be paid from the scheme in the event of my death

NAME:

SURNAME:

ID NUMBER:

RELATIONSHIP:

2nd Beneficiary Nomination

NAME:

SURNAME:

ID NUMBER:

RELATIONSHIP:

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PREMIUM PAYMENT

NAME:

SURNAME:

RANK:

STATION:

ID NUMBER:

PERSAL NUMBER:

AMOUNT:

START DATE:

DATE SIGNED:

When selecting payment via Persal, please also complete the Debit Order section to be used only in case of limit exceed

DEBIT ORDER AUTHORITY

ACCOUNTHOLDER NAME:

BANK NAME:

BRANCH NAME:

ACCOUNT NUMBER:

BRANCH CODE:

AMOUNT:

ACCOUNT TYPE:

START DATE:

**NB: If it is found that a participant is over the age limit when joining, any claim for this member will be repudiated and premiums refunded. Fax completed form to 086 673 2150 or e-mail to info@sapufuneral.co.za or contact our Call Centre on 087 110 0973/ 012 940 2616 or 012 362 0143

CONFIRM