FUNERAL COVER APPLICATION FORM by sdsdfqw21

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									                                                                        FUNERAL COVER APPLICATION FORM

  1. LIFE ASSURED’S DETAILS

ID Number:                                               Surname:

First Names:                                                                                            Title:

Former Names:                                                                                 Date of Birth:

Home Language:                                                                                Gender:          M     F

Marital Status:      Single     Married      Widowed         Divorced


   2. CONTACT DETAILS


Home Tel:                                           Business Tel:

Fax Number:                                              Cell Number:

Email:

   3. ADDRESS DETAILS

Postal Address:                                                                                                       Mailing Address (X)

                                                                                      Code:

Residential Address:

                                                                                      Code:

   4. LIFE ASSURED’S OCCUPATIONAL DETAILS (Please complete in full - essential requirements)

What is your present nominated occupation and since when?

During the past 5 years, have you been absent from work for a continuous period of more than one month as a result of an accident or illness?

   Yes       No

If yes, state nature of incapacity, periods and dates:

Nature of Duties:

   5. BENEFICIARY DETAILS

                  Name & Surname                           ID Number / D.O.B.                    Relationship                % Share




   6. DEPENDANTS DETAILS


                  Name & Surname                           ID Number / D.O.B.                    Relationship
    7. EXTENDED FAMILY DETAILS

                    Name & Surname                                       ID Number / D.O.B.                                   Relationship




   8. BEBEFITS

 Funeral Cover - Standard Family
    R 5 000 to Death           Rate - R60.25, including administration fee of R7.50                                                                        R

    R 10 000 to Death          Rate - R38.75, including administration fee of R7.50                                                                        R
 Funeral Cover - Extended Family

         Under 65                 Number of Members                                                                                                        R

       65 and over                Number of Members                                                                                                        R

  Total Monthly Premuim                                                                                                                                    R

    9. DEBIT ORDER DETAILS

 Account Holder:

 Bank:                                                                                                      Branch Code:

 Account Number:                                                                                        Branch:

 Account Type of : Savings              Current         Transmission

 If account holder is not the applicant, state the relationship:

 Have you collected the first months premium and attached it to this application form?                                     Yes            No

    10. Client Authority

 I declare that all sections of this application form has been fully considered by me and that the statements given in this application, whether in
 my handwriting or not, are strictly true and complete. I authorise Financial Management International Ltd. to draw on my bank account (as
 indicated above), the monthly premium required in terms of the benefits I have chosen. I agree that variations can be made if I am given 30
 days notice of a general increase or decrease on the monthly cost of this policy. I declare that the information given is true and complete to
 the best of my knowledge and belief and authorise any hospital , physician or other person who has attended to me to furnish FMI LTD or its
 representatives any and all history, consultations, prescriptions or treatment, and copies to all hospital or medical records. I am aware that I
 must forward all Claim Documentation to the Insurer of Financial Management International Limited within 15 days of initial notification of claim.
 I hereby apply for the Funeral Cover Plan and declare that I am currently in good health and that I am not under any medical treatment. I declare
 the above to be true and understand that my non - disclosure may result in the repudiation of a claim.

 Signature:                                                                                                                            Date:

 Commencement Date:

    10. Intermediary Details

 Brokerage:

 Broker:

 FMI Broker Code:                                                             FAIS Licence Number:

 FMI Broker Consultant:

 Signture:
                                                                                                                                                                  (


Financial Management International Ltd is an Authorised Financial Services Provider FSP 2717                                                                          FMi
                      Directors: PJ Cordial (AIB), SF Cordial (B Comm) , L Kujawa (BBusSci)(F.C.M.A) Secretary: SF Cordial (B Comm) Registration Number: 1995/006325/06

             Head Office: FMI House, Gleneagles Park, 10 Flanders Drive, Mount Edgecombe, 4300 PO Box 223, Mount Edgecombe, 4300 Telephone: (031) 538 3500 Fax: (031) 502 5250


                                                           Call Centre : 086 010 1119 Website : www.fmi.co.za

								
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