FutureBuilder Family Funeral Plan by ggy86211

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									 APPLICATION FORM:
 FutureBuilder Family Funeral Plan
Office Use                                                                                                                   New business
Policy reference no.                        6      0    0       5     8    0     1                                           Alteration to an existing policy (FLIP)
Policy number                  6   0   0                                         0                                           Agency Code
Amount                                                                                                                       Debit Order                       Stop Order                   Cash
1. Applicant for policy (If this application is accepted, the Applicant will become the Policy Owner)
 Surname                                                                              Maiden name                                                                Other initial(s)

 First name                                              ID no.                                                         Title                                   Sex Male              Female
 Marital status       Single                 Married                      Divorced                Widowed                                    Language Preference      Eng                  Afr
 Work address                                                                                                          Town/city                                             Postal code

 Postal address                                                                                                         Town/city                                            Postal code

 Tel no.      (h)                                           (w)                                          Fax no. (w)                                     Cell no.
 Forward policy to:       Postal address               Branch

 E-mail address
 Salary scale       0-3000             3001-4000            4001-6000                6001-8000            8001-10000          10001-12000             12001+
 Gross salary                                            Undisclosed salary

2. Premium Payer                        Complete this section only if Applicant and premium payer differ

 Surname                                                                                  Maiden name                                                            Other initial(s)

 First name                                              ID no.                                                         Title                                   Sex Male              Female

 Marital status       Single                 Married                      Divorced                Widowed                                    Language Preference
 Work address                                                                                                          Town/city                                             Postal code

 Postal address                                                                                                         Town/city                                            Postal code

 Tel no.      (h)                                           (w)                                          Fax no. (w)                                     Cell no.

  Relationship to Applicant                                               Are you interested in receiving information about new
                                                                          Metropolitan Group products and offerings in the future? Yes             No          Signature

  Company Name if institution is premium payer                                                                               Contact Person


3.1 Immediate Family
     Policy Owner              Policy Owner                  Policy Owner, Life                    Policy Owner          Retirement Premium             Cover level of
     only                      and Life Partner              Partner and Children                  and Children          Waiver                         Policy Owner

  Life Partner                                                                                     Other          Reason for difference in
                    Surname                                         First name                    initial(s)            surname                                     ID no.                       M/F


  Maiden name

 Children                                                                         Other          Reason for difference                                   If covering children older than 21 years,
                    Surname                            First name                                                      M/F          ID no.
                                                                                 initial(s)          in surname                                                        state reason




                                                                                                                             Immediate Family Sub-Total Premium

3.2 Funeral Services Benefit (for Policy Owner only)
  Funeral Services Benefit                                                                                                                                  Cover level
  This benefit will be paid in 6 equal monthly instalments on death of Policy Owner.
                                                                                                                        Funeral Services Benefit Sub-Total Premium




 15777 RSA (V01’09)
                                                          Metropolitan Life Limited is an authorised Financial Services Provider
                                                                                                                                                                    *15777*
4. Parents
                     Surname                                 First name and other initials                                    ID no.                 Cover level        Status**    Premium
  1.
  2.
  3.
  4.
 1 = Father 2 = Mother 3 = Father-in-law           4 = Mother-in-law       ** Indicate status      d = death     s = divorced                              Sub-Total Premium
 Reason for difference in surname
  1.
  2.
  3.
  4.
  I hereby declare that the Parents described above are my own legally recognised Parents and/or my Life Partner’s legally recognised Parents.

  Signature of Applicant                                                                Date (dd mm yyyy)

5. Extended Family
                   Surname                            First name and                     Relationship to                                           Cover          Add     Del.
                                                                                                                         ID no.                                                    Premium
                                                       other initials            M/F       applicant *                                             level          (A)     (D)
  1.                                                                                                                                                               A       D
  2.
  3.
  4.
  5.
  6.
  7.
  8.
  9.

I hereby declare that the person(s) indicated as Parent(s)/Parent(s)-in-law under Extended Family is/are                                                Sub-Total Premium
deemed as my “parent(s)” even if this/these person(s) is/are not my biological parent(s) or legal guardian(s).

Signature of Applicant                                                                 Date (dd mm yyyy)

6. Beneficiary
                   Surname                                    First name                            Title                                ID no.                             Relationship


 The benefits will be                  (a) on death of the Policy Owner and/or
 payable to the beneficiary:           (b) on death of any other person insured under the policy, provided the Policy Owner has predeceased such person.
7. Consent of spouse to beneficiary nomination (if applicable)
 The consent of the spouse is required where the beneficiary is not the Policy Owner’s spouse, or the spouse and one or more other persons have been nominated as joint beneficiaries,
 and      (a) the marriage is in community of property, and
         (b) the policy forms part of the joint estate.
 I hereby consent to the nomination of the aforementioned beneficiary(ies).                   Signature of spouse

 Name of spouse                                                                                       Date (dd mm yyyy)

8. Cash payment
 I agree to pay Metropolitan the cash amount due in terms of the policy.                                                               Total premium to be paid
 Date of first cash payment       (dd mm yyyy)
                                                                                                                  Signature of premium payer
 Payment dates thereafter (day of the month)

9. Stop order payment authority
 I authorise Metropolitan to draw from my salary the premiums due in terms of the policy and                                      Total premium to be deducted
 to increase the premiums due in terms of the policy from time to time. This authorisation is to
 remain in force until cancelled by me by giving written notice to Metropolitan.                               Date of first deduction (dd mm yyyy)

 Name of Employer                                                                                              Agency code
 Employee’s reference number                                                                                   Paypoint code/Department code

 Signed at                                                                        on this                            day of                                               year


 Signature of premium payer




15777 RSA (V01’09)                                                                                                                                                *15777*
10. Debit Order
 (Payments can only be made through a bank debit order by credit card/cheque/transmission or savings account)
 Name of account holder

 Master card          Visa        Cheque            Transmission           Savings                  Name of bank/
                                                                                                    building society
 Branch name                                                                                        Credit card no.

 Branch address                                                                                     Account no.
 Total premium to                                    Employer Code                                  Branch code
 be deducted
 Pay date                                                                                           Date of first deduction           (dd mm yyyy)
                                                                                                       End of month
 Debit order declaration Assignment:
 I authorise Metropolitan Life Limited (herein referred to as Metropolitan) to draw from my bank/building society account (whatever it may be) the premiums (and any short payments)
 due in terms of the policy, without prejudice to the rights of Metropolitan. I further authorise Metropolitan to increase the amount due in terms of the policy and authorise my bank/building
 society to effect payment of such increased amount upon receipt of notice from Metropolitan stating the increased amount and the date from which it is payable. This authorisation is to
 remain in force until cancelled by me by giving written notice to Metropolitan.
 I understand and agree that if a stop order has been submitted to provide payment for the premium under this policy and it cannot be implemented for whatever reason, this debit order
 will be put into effect.
 I agree that I am not entitled to recover any amount which has duly been drawn from the account by means of this debit order and I further agree that, in the event of my bank/building
 society repaying such amount to me, I will refund it to Metropolitan. I undertake to notify Metropolitan of any changes in respect of my address or my bank/building society.
 Signature of account
                                                                                                                              Date (dd mm yyyy)
 holder/premium payer
 Authorised Person                                                                                                            Capacity
 (if Institution)                                                                                                             (if Institution)

11. Replacement
 Is this application to replace the whole or any part of your existing insurance with any insurer (whether replacement is to occur immediately or                        Yes           No
 to replace an insurance discontinued within the past four months or within the next four months from the entry date)?
 If “yes”, the intermediary must discuss and complete the Replacement Policy Advice Record and attach it to this application form.
 Important
 Replacement of any insurance may be to the disadvantage of the Policy Owner.
12. Insurability
                                                                                                                                                  Life                    Extended
 The Applicant must answer the health questions on behalf of all the lives covered under this policy.                                  Applicant Partner Children Parents  Family
                                                                                                                                        Yes No Yes No Yes No Yes No Yes No
 12.1 In the past 6 months, have any of the lives covered been treated by a doctor or received medication?
 12.2 In the past 5 years, have any of the lives covered been treated at a hospital or clinic,
      or been treated by a specialist?
 12.3 Are any of the lives covered currently taking medicine that a doctor prescribed for health reasons?


  Further Particulars:
  If the answer to any of the questions in section 12 is “yes”, please give full particulars below:
  Where applicable, include the name of the insured life, when last symptoms occurred (month and year), as well as names and addresses of doctors, hospitals or institutions.
                                                                                                                                                                            Office use
     Question                         Name of insured life                                                             Particulars
                                                                                                                                                                       (Accepted or declined)




 Signature of
 Applicant                                                          Date (dd mm yyyy)


13. Particulars of family doctor /clinic
 Details of current family doctor or clinic of Applicant

 Address

 Town/city                                                                                       Country                                                 Postal code




 15777 RSA (V01’09)
                                                                                                                                                             *15777*
14. Declaration by Applicant (If this application is accepted, the Applicant will become the Policy Owner)
 1. I warrant that the information in this application and in all documents submitted to                 7. I understand that I am entitled to cancel this application within 30 days of the date of the
    Metropolitan Life Limited (herein referred to as Metropolitan) in connection with it,                   Policy Summary issued by Metropolitan. I agree that there will be a refund of all premiums
    whether in my handwriting or not, is true, correct and complete and will form the basis of              paid, less the cost of any cover enjoyed by me.
    the proposed contract.                                                                                   I understand that this right applies also to any application to increase the premium on an
 2. Accepting that I am hereby curtailing my rights of privacy, but to facilitate the assessment             existing policy and that any refund refers to the difference between old and new premium.
    of the risks, and the consideration of any claim for benefits, under a policy related to this        8. The Applicant becomes the Policy Owner if this application for insurance is accepted by
    or any other application for insurance made by me, or in respect of me as an insured life,              Metropolitan. Only the Policy Owner can take out cover on his/her life, cover for his/her
    I irrevocably authorise Metropolitan:                                                                   Life Partner, Children, Parents and Extended Family. The premium payer is not
      (a) to obtain from any person whom I hereby so authorise and request to give, any                     necessarily the Policy Owner and unless the premium payer is also the Policy Owner, the
          information which Metropolitan deems necessary, and                                               premium payer has no rights to the proceeds under the policy.
      (b) to share with other insurers that information and any information contained in this            9. I declare that I have received the policy Terms and Conditions and that the intermediary
          proposal or in any related policy or other document, either directly or through a                 explained the terms and conditions therein.
          database operated by or for insurers as a group, at any time (even after my death)             10. I understand that in terms of this product I qualify for certain FamilyAssistanceBenefits
          and in such detailed, abbreviated or coded form as may from time to time be                        that are provided by Europ Assistance Financial Services (Pty) Ltd. I understand that
          decided by Metropolitan or by the operators of such database.                                      Metropolitan will not be liable for any damages arising out of the provision or non-
 3. I understand and accept that my right of privacy may be infringed to the extent permitted                provision of such services.
    by me in this authorisation and I waive my right to privacy to that extent.                          11. Are you interested in receiving information about new Metropolitan        Yes       No
 4. I declare that I am in good health and that the insured lives (if any) covered under this                Group products and offerings in the future?
    policy are also in good health.
 5. I agree that if any material information concerning the risk on the insured lives/life have/has
    not been fully disclosed, or if I have given any untrue, incorrect or incomplete answers,
    Metropolitan reserves the right to cancel the cover and I shall forfeit all premiums paid.           Signature of Applicant
 6. I declare that I do not enjoy cover as a member of any voluntary group schemes policy
    which is underwritten by Metropolitan.                                                               Date (dd mm yyyy)
      Should Metropolitan discover at any stage that the insured lives do not qualify for this
      policy, Metropolitan reserves the right to cancel this policy with immediate effect and all
      premiums received up to the date of cancellation will be forfeited.


15. Information to be completed by intermediary(ies)
                              Name                                                        Commission numbers                                             Split                      Debit no.
                                                                                                         Sales manager/                                                       Regional
                                                                                     Intermediary       Broker consultant                                                      office     Sec.    Int.
 1.                                                                                                                                               .
 2.                                                                                                                                               .
  Maximum upfront commission allowed payable in advance to intermediary earned on total premium or premium increase:                          1st year                            2nd year

  Commission release options:                                                                                                                                                     TOTAL

        Commission payable in advance on issue of policy (I)                                             Commission payable in advance over 12 months as each premium is paid (M)
        Commission payable in advance on receipt of first premium (P)                                    Commission payable “as and when” over the premium-paying term (N)

  If FLIP then the commission release option will be as follows if any benefit is decreased or deleted:
  a. If previous “N” then commission release option must remain “N”
  b. For all other commission release options the commission release option must be “P”
  If FLIP then the commission release option will be as follows if any no decreased in premium:
  a. If previous “N” then commission release option must remain “N”
  b. For all other commission release options the commission release option must only be “I”
  Are you fully conversant with the ‘S’ referencing system embodied in the Life Offices’ Association Code of Conduct and do you consent to and accept its
  operation as well as the consequences thereof? Yes        No
  I declare that I have explained the meaning and implications of section 11 to the Applicant and that I am fully aware of the possible detrimental consequences
  of the replacement of an insurance policy.
  In the case of an independent intermediary:                    Please tick if independent intermediary
  I hereby declare and confirm that:
  -- I have identified the applicant mentioned in this application, as well as the person acting on behalf of the Applicant (if applicable) and have verified their identities
     according to the requirements as set out in the Financial Intelligence Centre Act, 38 of 2001 (the Act), and any legislation, regulations or guidelines related thereto.
     I further confirm that I will keep record of the verification documents as required in terms of the said Act and will make available copies of these documents and
     details of the verification procedures followed on request to any party thereto in terms of the Act; and
  -- I represent a Financial Services Provider authorised by the Financial Services Board in terms of the Financial Advisory and Intermediary Services Act No. 37 of 2002.
                                                                                             Signature of sales manager/
 Signature of intermediary                                                                   Broker consultant

                                                                                              Week number                                Date (dd mm yyyy)
 Signature of new
 business clerk                                                                                                                          Date (dd mm yyyy)

  Fit and Proper and Mandated Intermediary name                        Fit and Proper and Mandated Intermediary Commission number                            Contact number


  Fit and Proper and Mandated Intermediary signature                                Date
                                                                                                                                       Note: Complete if Fit and Proper and
                                                                                                                                       Mandated Intermediary is different from the
                                                                                                                                       above mentioned Intermediary
                                                                                       dd           mm             yyyy



15777 RSA (V01’09)                                                                                                                                                        *15777*

								
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