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Ezweni Funeral Plan Application Form

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Ezweni Funeral Plan Application Form Powered By Docstoc
					NestLife Individual Funeral Plan                                                                                    Application Form
PAYMENT METHOD:                    Bank Debit Order                                                                           Salary Stop Order

                                                                Main Member Details
Policy Number: NES                                           Inception Date:
Title:                                              Surname & First Name:
Date of birth:                                      ID No:
Occupation:
Postal address:
Phone No (H):                           Cell No:                                   Phone No (W):

                                                                Product Details
Product Name:           Option 1                                                         Option 2
Type of Plan:          Family                                  Single Parent                                                         Individual


                                                              Dependant Details
              Name                             Surname                Date of Birth/ID No:                Relationship               Additional Premium:




 Details of Extended Family Members                                   (If more than five ext. members please use separate sheet)
           Surname                            First Name                      Relationship            Birth Date / ID No         Sum                Premium
                                                                                                                                Assured            Per Month




                                                         Nominated Beneficiaries
Title             Initials                    First Name                       Surname                Birth Date / ID No      Relationship         Benefits




I, the applicant/policy holder under this policy, hereby nominate the above-mentioned person as the beneficiary in terms of this policy, to receive all
benefits payable under this policy. I hereby indemnify NestLife against any claim by myself or by my relatives/estate in respect of the payment of the
policy benefits to the beneficiary

 Bank Debit Order Authority                                                                                              Premium Calculation
Account Holder Name                                 Account Number                                                  Main Member Premium: R

Bank                                                Branch Code                                                     Additional Premiums       :R

Branch Name                                         Relationship to Member                                          Total Premium             :R
Account Type                                        Deduction Date                 Please tick(x) the applicable box below
     st                th               th              th               nd
 1                 7               15              20               22                  25 t h         26 t h            30/31 s t
I hereby grant NestLife Assurance permission to debit my bank account with the monthl y premiums on the nominated date (current or
arrears), incl udi ng amendments that may be made in terms or the contract and during the life of the contract. To avoi d bank charges
and possible cancellation of this policy, please ensure that there are sufficient f unds i n your bank account on the date of the deduction.
Signature Of Account Holder:………………………………………….Date:……………………………..
                                                                     Underwritten by:




                                                    An authorised financial services provider: FSP No. 6409
                                                                  Salary Deduction Details
I, ……………………………………………………the undersigned premium payer with ID Number
SALARY No: ………………………………………DEPARTMENT: ………………………………………..INSTITUTION: ……………………………………PAY POINT:……………………..
hereby authorize the accountant of my department to deduct from my salary a monthly premium equal to R………………………………………….The first
deduction is to be made at the end of the month of ………………………………………20……….. the premium stated must be remitted to NestLife Assurance Corporation Limited
from whom I have purchased a funeral policy. Should the premium be adjusted by the company, I agree that the adjusted premium may be deducted
from my salary until such time as I cancel this authority in writing or until substitute it with a new authority. I hereby understand that should a deduction
not be made for any reason, my monthly premium shall not be paid over to NestLife Assurance Corporation Limited by my employer, and furthermore that I will
be responsible for the payment. Should my payment as stated and agreed upon on the stop order not be received by the 7th of every month, my benefits
will be with withdrawn.

SIGNED AT: ……………………………………………… DATE: ……………………………………….SIGNATURE OF PREMIUM PAYER/EMPLOYEE:…………………………………..



                                                                        Health Declaration
Is anyone on this policy suffering from any illness? ____Yes_____No, If yes, please provide
details:__________________________________________________________________________________________________________________

         __________________________________________________________________________________________________________________

Signature :______________________Date:_________________


                                                                   Premium Payer Details
Name & Surname
ID No.
Phone No (H):                                                 Phone No. (W):                                                Cell No:

                                                                            Agent Details
Name :                                                        Surname:
Agent Code :                                                  Signature

                                                                               Declaration
I hereby apply for the NestLife Funeral Plan in accordance with the conditions and exclusions of the plan as set out in the quotation and policy document. I understand that a
policy summary, including my personal details, chosen benefits and claims procedures (as intended in Section 48 of the Long-term Insurance Act), will be posted to me. In
accordance with the Long-term Insurance Act, you have 30 (thirty) days, any payment that has been received will be refunded. I am aware of the waiting periods applicable to
this policy. There is a limit of (1) one policy per Main Member under the Nestlife Funeral Plan. I, the undersigned, hereby declare and warrant that all information supplied
herein, is true and complete. I am aware, and understand that any non-disclosure or misrepresentation which is material to the determination of the risk by NestLife, may lead
to the policy being declared null and void, in which case all premiums paid, will be forfeited. I am certain that the product which I am applying for, meets my needs and feel
that I have all the necessary information in order to make an informed decision in respect of the purchase thereof. The Long-term benefits under this policy are subject to the
provisions as set out in NestLife's Statutes and the provisions of the master policy. The long-term policy shall come into force and effect on the inception date provided that the
offer for insurance made by the Policyholder by way of the proposal form is unconditionally accepted by NestLife and the first premium payable in terms of the Policy was
received by Nestlife.


Signature of Main Member / Policy Holder: …………………………………Date:………………….




       Terms & Conditions

                   •        Max age at entry for member and spouse is 65
                   •        Max age at entry for parents is 75
                   •        Max of 6 children
                   •        Max of 4 parents (including in-laws) – can only be added at inception
                   •        6 months waiting period members up to 65years
                   •        A 9 month waiting period for members for members between 65 to 74years
                   •        24 month suicide exclusion
                   •        The waiting period is waived in the event of accidental death
                   •        There is no refund of premiums on withdrawal or death of the principal member




                                                                               Underwritten by:




                                                              An authorised financial services provider: FSP No. 6409

				
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posted:2/14/2011
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