Khanyisa | New Leads

PRINCIPAL MEMBER DETAILS

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Select Scheme Option :

Region :

Cell Number :

Email :

Khanisa Agent :

Shop Steward :

APPLICATION FOR VOLUNTARY FUNERAL ASSURANCE WITH EXTENDED FAMILY BENEFITS

Region :

Station :

Surname :

Name :

ID Number :

Age :

Cell Number :

Work Number :

Premium R:

Email :

SAPU Number :

Postal Address :

Residential Address :

UMNGCWABO :

Policy Number :

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PERSONAL DETAILS OF SPOUSE:

Surname :

First Name :

ID Number :

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Premium R:

UMNGCWABO :

PRINCIPAL MEMBER’S OWN CHILDREN DETAILS:

Name:	ID Number:	UMNGCWABO:	Preminum:
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TOTAL IMMEDIATE FAMILY PREMIUM:

WIDER CHILDREN’S DETAILS:

Name:	ID Number:	Premium:
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TOTAL WIDER CHILDREN PREMIUM:

EXTENDED FAMILY DETAILS:

Name:	ID Number:	REPATRIATION PREM	UMNGCWABO	COVER AMOUNT	PREM	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 + Umngcwabo / 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:

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PREMIUM PAYMENT

NAME :

SURNAME:

RANK:

STATION:

I.D NUMBER :

PERSAL NUMBER:

AMOUNT:

START DATE:

DATE:

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