Document Sample
					                                  THE KGA CHRISTMAS BONUS
                                        FUNERAL PLAN
                       Underwritten by                                                                                      Membership No.

                                                      This scheme is insured in
                                                      terms of the insurance act no.                         Notes:
                                                      52 of 1998 and underwritten                            1. Write in BLOCK capitals, using black ink.
                                                      by KGA Life Ltd.
                                                                                                             2. Tick the relevant boxes unless otherwise indicated.
                       Reg. No. 1998/023657/06

Where did you hear about the product?


 Surname                                                                                     Title               Mr   Mrs    Ms   Marital Status   Married   Single   Divorced   Widowed

 First names                                                                                 ID Number                                                                        Sex M   F

                                                                                             Date of Birth                                             Age Next Birthday

 Postal Address                                                                              Residential
                                                                                             (if different to
                                                                                             Postal Address)
                                                          Postal Code                                                                                  Postal Code

 Tel No. (h)                                                                                 Fax No.

 Tel No. (w)                                                                                 E-mail Address

 Cell No.                                                                                    Language            A                E

 Describe duties of your job

 Gross Monthly Income                                         R                              Postal Address
                                                                                             of Employer
 Employer's name

 Company Tel No.                                                                                                                                       Postal Code

A.    Spouse and children details for which cover is required. (maximum 5 children).
B.    Note: Cover is only available for children up to but not including 26 years at date of commencement (see section M general rule 4).
C.    Cover is only available for biological and legally adopted children. No extended family allowed.

If Common Law Spouse, indicate with X

 Spouse Surname                                                                     Maiden Name                                                                         Sex       M   F

         First Names                                                                    ID Number                                                                       Age

     Child 1 Surname                                                                   First Names                                                                      Sex       M   F

          ID Number                                                                                                                                                     Age

     Child 2 Surname                                                                   First Names                                                                      Sex       M   F

          ID Number                                                                                                                                                     Age

     Child 3 Surname                                                                   First Names                                                                      Sex       M   F

          ID Number                                                                                                                                                     Age

     Child 4 Surname                                                                   First Names                                                                      Sex       M   F

          ID Number                                                                                                                                                     Age

     Child 5 Surname                                                                   First Names                                                                      Sex       M   F

          ID Number                                                                                                                                                     Age

 E12 12/07
The member can choose between an annual R1 000 or R500 withdrawal. Indicate with X

                                                                                                        R1 000                  R500
   Age Group of premium paying member                                                                                                              Premium
                                                                                                      withdrawal             withdrawal

   14 - 24 Inclusive                                                                              R135.00                R 95.00              R

   25 - 44 Inclusive                                                                              R145.00                R105.00              R

   45 - 59 Inclusive                                                                              R155.00                R115.00              R

   60 - 74 Inclusive                                                                              R180.00                R140.00              R

                                                                                                                        Monthly Policy Fee    R        15.00

                                                                                                             TOTAL MONTHLY PREMIUM            R

Have you or any of your dependants been diagnosed or treated in the last 2 years for:

                                                  YES            NO               4 Cancer                                             YES        NO
1 Tuberculosis

2. HIV Aids                                       YES            NO               5. Kidney failure                                    YES        NO

3. Heart condition
                                                  YES            NO               6. Have you or any of your dependants
                                                                                     family been bedridden for a period
Have you or any of your dependants                                                   of more than 3 months?                            YES        NO
received treatment from a doctor or                                                   Have you or any of your dependants
clinic for the same illness on more                                                   been hospitalized for any illness
than one occasion during the past                 YES            NO                   during the past year?                            YES        NO
If you answered "YES" to any of the above questions, please provide full details: (Telephone number and name of Doctor/Clinic/Hospital plus dates and nature of

I, the main member hereby nominate the person named below to receive the proceeds of this policy in the event of my death.

First Names:                                                                          Surname:

Relationship:                                                                             ID Number:

Signature of Main Member

Immediate Cover will only be approved if a written application for renewal of the policy is received by KGA Life within 30 days after the maturity of a persons
Christmas Bonus Funeral Plan.

Policy No.:                                                                                             Date Matured:

IC Approved:            YES                   NO                                                       New Business:
                                                                                                                                 YES         NO

   SECTION G : KGA ASSIST ( 24 hours p.d. )
KGA Assist provides the following added value services 24 hours per day:
           •Funeral support / repatriation of mortal remains to Funeral Parlour nearest to the place of burial anywhere in SA.
           •Legal Assistance / helpline for Criminal, labour and civil matters.
           •Access Health Line for any health related matters.
           •Emergency Evacuation to the nearest hospital with guaranteed admittance.
                                               Call KGA Assist on: 0860 000 535      Policy Enquiries : 021 944 6300
                                                                          * Payment by debit order is only available to persons with a gross income over R 3 500 per month.
Method of Payment      Stop Order           *Debit Order                  * Payment of premiums by an employer is acceptable.
Note: If the first premium is not received on or before the commencement date, the commencement date will become the 1st day of the month following the
receipt of the first premium by KGA Life Limited.

I, hereby request KGA LIFE LIMITED to arrange with my bank and pay point administrator to collect by means of the debit order system the premiums as
 amended from time to time against:

Account Number

Name and branch of the bank                                                                                                     Branch Code

Type of Account        Current        Transmission      Savings            Please attach proof of banking details (Cancelled cheque/bank stamp/letter from bank).

                              D   D     M M   Y   Y    Y   Y
Monthly with effect from                                          and monthly thereafter, the amount of R

Full names of account holder
I acknowledge that KGA Life Limited and / or the pay point administrator may not cede any of its rights to any third party without my prior written consent and that
I may not delegate any of my obligations in terms of this contract / authority to any third party without the prior written consent of KGA Life Limited.

Signed at                                                      on this               day of                     20
                                                                                                                                    Account Holder's Signature


                                                                                                                        Table          114         Code

I, (full name)                                                                         Identity Number

Rank                       Salary No.                 hereby authorise the Accountant of the Department of

to deduct a monthly premium of R                 with effect from                20            from my salary and to remit it to KGA LIFE LIMITED
from whom I have obtained insurance until such time as I cancel this authorisation in writing, or until I substitute it with a new authorisation.
Should the relevant premium be adjusted by the Institution as a result of a general decrease/increase in premium I confirm that the adjusted premium (including
stamp duty) may be deducted from my salary, until such time as I cancel this authorisation in writing or until I substitute it with a new authorisation.

Signed at                                                      on this               day of                     20
                                                                                                                                         Members Signature

I/We accept the waiting periods, and all conditions (including dreaded diseases), as contained in the Master Policy and as explained to me/us by the broker. I/We
authorise KGA Life Ltd to obtain from any doctor, or any other person, any necessary medical information, even after my/our death. I/We understand that untrue
statements and / or information not disclosed, can lead to policy cancellation.

Signature of Main Member:                                                                            Date:

Signature of Spouse:                                                                                 Date:


KGA Code:                         Name of Brokerage/Agency:                                                            Brokerage/Agency Code:

Broker's/Agents initials and surname:                                              Broker/Agent Code:                           FSP Licence Code:

I declare that, to the best of my knowledge and belief, no money has been or will be paid or advanced to the main member by me or by anybody else as an
inducement to effect this insurance, and that no other consideration has been offered to the main member. I further declare that the main member has in no way
been misled by me or, as far as I am aware, by anybody else with regard to the terms and conditions of the policy concerned.

Date:                                                                                           Signature of Broker/Agent:

1. This is a 10 year term policy linked to a savings plan which pays out R500 or R1000 on the 1st of December each year. A pro-rata amount is paid out in the first and last year
    depending on the entry date of the policy.
2. Applicants who are in the age group 18 up to 74 years may participate in the scheme.
3. Members who are not legally married but living together as a family can still enjoy family benefits provided that all the relevant particulars are declared on the application form.
4. Cover in respect of children will include unmarried children up to but not including the age of 21. Cover is extended up to but not including the age of 26 if the child is an unmarried
   full-time student. Cover for physically or mentally disabled children who are dependant on their parents will continue to be covered under this plan, irrespective of age, provided
   premiums are paid. Physically or mentally disabled children who receive a disability grant do not enjoy cover.
5. The onus will be on the premium paying member and his spouse to ensure that monthly premiums are paid promptly to KGA Life Limited. Cover will cease on the non payment of
6. A policy that lapses during the first four months will result in the cancellation of the policy. The member will have to apply for a new policy and the relevant waiting period will apply.
7. Where the policy lapses from month 5 onwards the member will be able to reinstate the policy, however, an admin fee of R100 will be charged.
8. Premiums are payable monthly in advance, on or before the first day of each month.
9. Premiums under the scheme are not guaranteed and can be adjusted by KGA Life Limited at any stage.
10. If a member's cover should cease and the member applies to rejoin the scheme at a later stage the same conditions as for new membership will apply.
11. Membership under the scheme can only commence on the 1st day of a month following the receipt of the first premium by KGA Life Limited.
12. An application for membership which is received during a month will, if accepted, only be admitted as a member of the scheme from the first day of the month following receipt of the
    first premium. Cover will commence after the stipulated waiting period has expired.
13. Members and lives assured will be subject to a six (6) calendar month waiting period for benefits. Cover will only commence six (6) calendar months after receipt of first
14. Cover for death as a result of suicide is excluded for a membership period of two (2) years.
15. Cover for death, as a result of an accident, is available after receipt of the first premium.
16 If a member has answered yes to any of the medical questions (1-5) under section D, the application will be accepted but, the waiting period applicable to that specific
   dreaded disease will be 24 months.
17. Only claims submitted within six (6) months from the date of death will be considered for payment.
18. Claims for common-law spouses not declared on the application form will not be considered for payment in the event of death. (Traditional marriages included).
19. The rules of this scheme are not inconsistent with the provisions of the Long-Term Insurance Act (Act 52 of 1998) or with terms of the Master Policy.
20. The Master Policy is available for inspection at the head office of KGA Life Limited. The Master Policy contains the full rules & conditions of this contract. Should there be a
    discrepancy the conditions as set out in the Master Policy will prevail.


                                                                     KGA CHRISTMAS BONUS FUNERAL PLAN
                                                                                                                Admin and
   Age                                                       Risk and Savings                                 Marketing Costs                                       Premium

   14 - 24 inclusive                                       R 65,00 / R 105,00                                      R 30,00                                   R 95,00 / R 135,00

   25 - 44 inclusive                                       R 75,00 / R 115,00                                      R 30,00                                   R 105,00 / R 145,00

   45 - 59 inclusive                                       R 85,00 / R 125,00                                      R 30,00                                  R 115,00 / R 155,00

   60 - 74 inclusive                                       R 110,00 / R 150,00                                     R 30,00                                   R 140,00 / R 180,00


Risk Approved: YES / NO                          Name:                                                                 Signature:


I.C. Approved: YES / NO                          Name:                                                                 Signature:

KGA Portfolio / Regional Manager / Office Manager                                                                            Date:

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