THE KGA CHRISTMAS BONUS
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?
SECTION A : MAIN MEMBER
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 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
Company Tel No. Postal Code
SECTION B : FAMILY COVER
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
SECTION C : PREMIUMS
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
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
SECTION D : MEDICAL QUESTIONNAIRE
Have you or any of your dependants been diagnosed or treated in the last 2 years for:
YES NO 4 Cancer YES NO
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
SECTION E : NOMINATION OF BENEFICIARY
I, the main member hereby nominate the person named below to receive the proceeds of this policy in the event of my death.
DETAILS OF NOMINATED BENEFICIARY:
First Names: Surname:
Relationship: ID Number:
Signature of Main Member
SECTION F : IMMEDIATE COVER
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:
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
SECTION H : PAYMENT OPTIONS
* 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:
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
SECTION I : STOP ORDER
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
SECTION J : DECLARATION BY MEMBER
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:
SECTION K : DETAILS OF BROKER/AGENT
KGA Code: Name of Brokerage/Agency: Brokerage/Agency Code:
Broker's/Agents initials and surname: Broker/Agent Code: FSP Licence Code:
SECTION L : DECLARATION AND SIGNATURE OF BROKER?AGENT
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:
SECTION M : GENERAL RULES OF THE KGA CHRISTMAS BONUS FUNERAL PLAN
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.
PREMIUM STRUCTURES (POLICY FEE EXCLUDED)
KGA CHRISTMAS BONUS FUNERAL PLAN
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
OFFICE USE ONLY
Risk Approved: YES / NO Name: Signature:
I.C. Approved: YES / NO Name: Signature:
KGA Portfolio / Regional Manager / Office Manager Date:
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