Title (Main Member): Surname:
First Names: Date of Birth:

Email Address:
Address:

Tel. No: ID. No:
Age: Sex:
Policy No: Cover: Burial
 Family  Single

Are all the members listed in good health?:  Yes  No    (F.S.B. Requirements)

I, the undersigned, wish to become a member of the Funeral Scheme, I understand that cover will only apply to my dependents as set out below. I abide by all the rules, regulations and exclusions as set out in my policy document / burial book. I understand that any incorrect ID's, Date of Birth's, wrong information or non information (no Birth Dates) given by me will NULLIFY a claim.

 Tick, if you the policy holder agree

SURNAME FIRST NAME RELATIONSHIP DATE OF BIRTH
Spouse
Child
Child
Child
Child
Child

If extra dependants, please add information, you must inform us of new births and marriages:

Debit Order - Payers Details
I, the undersigned, request you to arrange with my bank to collect the premiums payable in terms of a Debit Order. Please note that F.N.B. Savings Account (BOBSAVE) UNITED HELP U PLUS, Afican Bank & Post Office Accounts are not debitable.

Particulars of Account Holder (Surname, Initials):

ID.No: Date of Birth:
Bank: Branch:
Date of First Withdrawal
(25th or 1st only):
Type of Account:
Account No.: Branch code:

  Tick, if you agree the above information is correct:

Date:

R100.00 ONCE OFF JOINING/ADMIN FEE MUST BE PAID IN CASH WITH APPLICATION.




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