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1.
APPLICANT DETAILS
*
Indicates required field
Title
*
Full Names
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Surname
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ID Number
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Inception Date
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Current Age
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Employer
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2.
CONTACT DETAILS OF APPLICANT
Postal Address
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Postal Code
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Residential address
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Postal Code
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Phone Number (Home)
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Phone Number (Work)
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Cellphone Number
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Email
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3.
FUNERAL COVER REQUIRED
Select the FUNERAL COVER amount:
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R10 000 cover will cost you R35.03 per month
R15 000 cover will cost you R50.57 per month
R20 000 cover will cost you R65.50 per month
R25 000 cover will cost you R80.74 per month
4.
FUNERAL COVER QUALIFYING CO-INSUREDS
Qualifying co-insureds: 1 Spouse and maximum of 10 children (own, step-, legally adopted children)
Name
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First
Last
Name
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First
Last
Name
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First
Last
Name
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First
Last
Name
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First
Last
Name
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First
Last
Name
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First
Last
Name
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First
Last
Name
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First
Last
Name
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First
Last
Name
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First
Last
ID NUMBER
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ID NUMBER
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ID NUMBER
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ID NUMBER
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ID NUMBER
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ID NUMBER
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ID NUMBER
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ID NUMBER
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ID NUMBER
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ID NUMBER
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ID NUMBER
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Relationship (Please select one):
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SPOUSE
CHILD
Relationship (Please select one):
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SPOUSE
CHILD
Option 3
Relationship (Please select one):
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SPOUSE
CHILD
Option 3
Relationship (Please select one):
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SPOUSE
CHILD
Option 3
Relationship (Please select one):
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SPOUSE
CHILD
Option 3
Relationship (Please select one):
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SPOUSE
CHILD
Option 3
Relationship (Please select one):
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SPOUSE
CHILD
Option 3
Relationship (Please select one):
*
SPOUSE
CHILD
Option 3
Relationship (Please select one):
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SPOUSE
CHILD
Option 3
Relationship (Please select one):
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SPOUSE
CHILD
Option 3
Relationship (Please select one):
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SPOUSE
CHILD
Option 3
5. DEATH, DISABILITY AND CRITICAL CONDITION COVER REQUIRED
Please note that Disability and/or Critical Condition cover cannot be taken without Death cover.
If Disability and/or Critical Condition cover is required, the amount of cover must match the Death cover amount.
Death Cover Amount and your Monthly Premium
*
R100 000 cover | Your Premium will be R102.59
R250 000 cover | Your Premium will be R253.93
R500 000 cover | Your Premium will be R505.98
R750 000 cover | Your Premium will be R758.03
R1 000 000 cover | Your Premium will be R1010.08
Select Your Death Cover Amount by scrolling down the list and click on the cover required.
Disability Cover and your Monthly Premium
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R100 000 cover | Your Premium will be R51.24
R250 000 cover | Your Premium will be R126.70
R500 000 cover | Your Premium will be R252.46
R750 000 cover | Your Premium will be R378.22
R1 000 000 cover | Your Premium will be R503.98
Select your Disability Cover amount by scrolling down the list and selecting the applicable cover amount.
Critical Condition Cover and your Monthly Premium
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R100 000 cover | Your Premium will be R38.74
R250 000 cover | Your Premium will be R95.09
R500 000 cover | Your Premium will be R188.16
R750 000 cover | Your Premium will be R280.84
R1 000 000 cover | Your Premium will be R373.52
Select your critical condition cover amount by scrolling down the menu and select the cover amount.
6.
TOTAL PREMIUM
In the table below, fill in your total monthly premium(s) as selected from the drop-down menus above. Your total monthly premium will be calculated accordingly. If you are unsure about the amount, please refer to the images on the right below. If you want to enlarge the image, simply click on the image.
7.
BENEFICIARY INFORMATION
A. NOMINATION OF BENEFICIARY UPON DEATH OF THE PRINCIPAL MEMBER Should you fail to nominate a beneficiary, the benefit will be paid into your estate.
Nominated Beneficiary (Name And Surname):
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Nominated Beneficiary ID Number:
*
I, the undersigned, nominate the aforementioned person/institution as the beneficiary of the benefit upon my death.
The Principal member must notify
Futura SA Administrators (Pty) Ltd
in writing of any change relating to the payment instruction and/or nominated beneficiary.
I, (Full in Full Name of Principal Member)
Name
*
First
Last
With ID Number (Principle Member)
*
certify that my personal financial circumstances have been fully discussed with me. I confirm that I am in a position to afford the funeral insurance cover indicated and that I consider it essential for my family/personal needs.
I declare, to the best of my knowledge and belief, that the particulars given by me herein are true and correct. I am satisfied that the plan chosen by me, best suits my needs, I am able to afford the total monthly contribution of the plan chosen by me. I have read and understood the Summary of the Terms and Conditions provided to me.
B. This section must only be completed if you do not wish the benefit to be paid to yourself upon the death of a family member.
PAYMENT INSTRUCTION FOR BENEFIT PAYABLE UPON DEATH OF A FAMILY MEMBER (FUNERAL BENEFIT)
Name and Surname of PAYEE
*
First
Last
ID NUMBER of PAYEE
*
I, the undersigned, hereby instruct that the benefit upon the death of a family member, be paid to the aforementioned person/institution on my behalf.
The Principal member must notify Futura SA Administrators (Pty) Ltd in writing of any change relating to the payment instruction and/or nominated beneficiary.
8.
DECLARATION BY APPLICANT (PRINCIPAL MEMBER)
I
hereby acknowledge that I did not receive any advice from a financial advisor regarding the Unison product and that I commit to engage in this product out of my own free will without any persuasion or interference from an intermediary. I confirm that I fully understand the particulars of the product as it is reflected on the product provider’s website and that the product is suitable for my financial needs.
I confirm that I fully understand the manner on which the premium is calculated and I further confirm that I can afford the premium which relates to the options I have chosen.
Digital Signature - By typing my full name and surname in the space below, I the principle member, confirm that I read the terms and conditions and agree with it.
*
I have read the disclaimer and understand the content of it
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Scheme Entry Date (1st of Month):
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I have read and understand the terms and conditions of the disclaimer
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YES
NO
For a copy of the disclaimer, please click HERE.
This product is underwritten by Capital Alliance Group Risk – a division of Capital Alliance Life Limited (Reg. No. 1969/008187/06) – a wholly owned subsidiary of Liberty Group Limited. Capital Alliance Life Limited – an Authorised Financial Services Provider in terms of the FAIS Act (Licence No. 17404). The scheme is administered by Futura SA Administrators (Pty), an authorized Financial Services Provider licensed by the Financial Services Board in terms of the FAIS Act License number 18287. Address: 63 Lincoln Road, Boston, Bellville, 7530.
9.
DEBIT ORDER AUTHORITY
BANK DEBIT ORDER INSTRUCTION:
Name
*
First
Last
Phone Number
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Address:
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Date:
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Policy Number:
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Debit Amount:
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Commencement Date:
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Dear Sirs/Madams
The details of my/our account are as follows:
BANK NAME:
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BRANCH TOWN:
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BRANCH NUMBER:
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ACCOUNT NUMBER:
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ACCOUNT NAME:
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ACCOUNT TYPE (Please select one):
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TRANSMISSION ACCOUNT
CHEQUE ACCOUNT
SAVINGS ACCOUNT
This signed Authority and Mandate refers to our contract as dated as on signature hereof ("the Agreement"). I / We hereby authorize you to issue and deliver payment instructions to the bank for collection against my / our above-mentioned account at my / our above mentioned bank (or any other bank or branch to which I / We may transfer my / our account) on condition that the sum of such payment instructions will never exceed my / our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me / us by giving you notice in writing of no less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above. The individual payment instructions so authorized to be issued must be issued and delivered as follows:
On the (Fill in date - YYYYMMDD) for the payment day
*
of each and every month commencing on (Fill in date YYYYMMDD):
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In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account; Monthly; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less that the obligation due;
I / We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.
MANDATE
I / We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally.
CANCELLATION
I / We agree that although this Authority and Mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.
ASSIGNMEN
T
I / We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.
Signed at (place):
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On date (YYYYMMDD):
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Digital Signature - By typing my full name and surname in the space below, I the principle member, confirm that I read the terms and conditions and agree with it.
*
Assisted by (Name Agent):
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Futura SA Administrators (Pty) Ltd is an authorized Financial Services Provider licensed by the Financial Services Board in terms of the FAIS Act License number 18287. Address: 63 Lincoln Road, Boston, Bellville, 7530
Submit
TO DOWNLOAD THE APPLICATION FORM IN WORD FORMAT, CLICK HERE
TO DOWNLOAD THE APPLICATION FORM IN PDF FORMAT, CLICK HERE
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