Documenti di Didattica
Documenti di Professioni
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Details of spouse
ID Number Surname Title Full first names Initials Gender Male Female
1. 2. 3. 4. 5.
1. 2. 3. 4. 5.
Total premium
Nominated beneficiary
Title Initials Surname Identity number Relationship
I, the applicant / member 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 Assupol Life against any claim by myself or my relatives / estate in respect of the payment of the policy benefits to the nominated beneficiary.
Details of benefits
Family funeral plan
Plan A Family 18 - 65 years Monthly premium R 5 000 R60.00 Plan B R 6 000 R70.00 Plan C R 7 500 R80.00 Plan D R10 000 R90.00 Family 66 - 75 years Monthly premium Plan E R 5 000 R140.00 Plan F R 6 000 R180.00 Plan G R 7 500 R160.00 Plan H R10 000 R170.00
Underwritten by
Life Limited
Head office 308 Brooks street, Menlo Park, Pretoria, 0081 Assupol Life Limited reg no 2010/025083/06 An authorised financial services & credit provider
Date
Date
Date
Date
Declaration by representative
Surname Initials ID number
I hereby declare and warrant that no money has been or will be paid or advanced to any insured life on this policy by me or any other party as an inducement to effect this insurance and that no other consideration has been offered to any insured life. I further declare that no insured life on this policy has in any way been misled by me or as far as I am aware by any other party with regard to the terms and conditions of the policy applied for. I further declare that I have explained the meaning and implications of replacement of an insurance policy to the policy owner and that I am fully aware of the possible detrimental consequences of the replacement of an insurance policy.
Signature of representative
Representative code
Date
Underwritten by
Life Limited
Head office 308 Brooks street, Menlo Park, Pretoria, 0081 Assupol Life Limited reg no 2010/025083/06 An authorised financial services & credit provider