Our System indicates that you already have a sale in progress for
Thank you for choosing to buy your ID number , your income before tax and bank details available. You must be the account holder of the bank account that will be debited. Once you have completed all the steps and purchased your policy. Documents will be emailed to you, which will have all the details of your new policy.
Please enter your email address in order to start the application or to continue on an existing application.
Now, tell us who you are?
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Do you have another number for us?
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Where will we send your policy documents?
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Tell us more about you?
Monthly Income
?
This is your monthly salary before expenses
Occupation
?
What industry do you currently work in?
Education
?
What is your highest level of education achieved
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How much annual cover do you want?
Please select the amount you would require to be paid out to your beneficiaries should you pass away.
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Add Rewards?
Add Clientele Rewards to access significant savings on groceries, bus tickets and store gift cards.
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Would you like to add a spouse?
Please select "Yes" if you also want your spouse to be covered on this plan in case of death. Your spouse will be covered at no additional cost and their cover will be equal to the cover selected for yourself.
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Tell us more about your spouse
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949
Please provide the date of birth of your spouse. Your spouse will need to be between the ages of 18 and 79 to qualify for cover.
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Would you like to add Child/Children?
Please select "Yes" if you have any children that you would like to cover on this plan. Up to
Death Benefits for Children explained.
Death benefits for children are subject to restrictions and will be paid out as per below table.
Age at claim event Benefit (irrespective of Benefit Amount)
Below the age of 2
R2,500
2 – 5
R5,000
6 – 13
R10,000
14 – 18
100% of the Total Funeral Benefit
Children up to the age of 21 years may remain on the policy provided they are full time students, attending a registered institution (proof of registration will be required at claims stage.)
Death Benefits for Children explained.
Annual cover for children is subject to restrictions and will be paid out as per below table.
Age at claim event Percentage of benefit
Up to the age of 4
50%
4-18
100%
In addition Cover for Children under 6 years of age is limited to R10,000 per annum and Cover for Children between 6 and 14 years of age is limited to R30,000 per annum.
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How many children would you like to add?
Please select how many children you want to add to the plan. You can cover up to 3 children at no additional cost. Your child's cover will be equal to the cover selected for yourself.
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Tell us more about the child/children you want to add?
Child 1
Children over 18 to 21 must be full-time students.
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998
Please enter the date of birth of the child you would like to add to your plan, as we need to know their age.
Child 2
Children over 18 to 21 must be full-time students.
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998
Please enter the date of birth of the child you would like to add to your plan, as we need to know their age.
Child 3
Children over 18 to 21 must be full-time students.
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998
Please enter the date of birth of the child you would like to add to your plan, as we need to know their age.
Child 4
Children over 18 to 21 must be full-time students.
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998
Please enter the date of birth of the child you would like to add to your plan, as we need to know their age.
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Any other family member(s) you wish to cover?
You can add up to 8 additional members to be covered by this plan. The premium will be based on the age of each member.
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How many extended family members do you want to cover?
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Tell us more about the family member(s) you wish to cover on your plan
Pay Back Benefit
Would you like to include the Premium Pay Back benefit for your extended family?
Please select
Yes
No
Please note: Premium Pay Back benefit will be added to all or none of the covered extended members.
Extended Member 1
Gender
Male
Female
Relation
ID number (optional)
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Please provide the correct date of birth as this will determine your premium.
Member Cover
R5 000
R10 000
R15 000
R20 000
R25 000
R30 000
R35 000
R40 000
R45 000
R50 000
Each extended member's cover needs to be equal to or less than the cover of the main member.
Extended Member 2
Gender
Male
Female
Relation
ID number (optional)
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Please provide the correct date of birth as this will determine your premium.
Member Cover
R5 000
R10 000
R15 000
R20 000
R25 000
R30 000
R35 000
R40 000
R45 000
R50 000
Each extended member's cover needs to be equal to or less than the cover of the main member.
Extended Member 3
Gender
Male
Female
Relation
ID number (optional)
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Please provide the correct date of birth as this will determine your premium.
Member Cover
R5 000
R10 000
R15 000
R20 000
R25 000
R30 000
R35 000
R40 000
R45 000
R50 000
Each extended member's cover needs to be equal to or less than the cover of the main member.
Extended Member 4
Gender
Male
Female
Relation
ID number (optional)
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Please provide the correct date of birth as this will determine your premium.
Member Cover
R5 000
R10 000
R15 000
R20 000
R25 000
R30 000
R35 000
R40 000
R45 000
R50 000
Each extended member's cover needs to be equal to or less than the cover of the main member.
Extended Member 5
Gender
Male
Female
Relation
ID number (optional)
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Please provide the correct date of birth as this will determine your premium.
Member Cover
R5 000
R10 000
R15 000
R20 000
R25 000
R30 000
R35 000
R40 000
R45 000
R50 000
Each extended member's cover needs to be equal to or less than the cover of the main member.
Extended Member 6
Gender
Male
Female
Relation
ID number (optional)
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Please provide the correct date of birth as this will determine your premium.
Member Cover
R5 000
R10 000
R15 000
R20 000
R25 000
R30 000
R35 000
R40 000
R45 000
R50 000
Each extended member's cover needs to be equal to or less than the cover of the main member.
Extended Member 7
Gender
Male
Female
Relation
ID number (optional)
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Please provide the correct date of birth as this will determine your premium.
Member Cover
R5 000
R10 000
R15 000
R20 000
R25 000
R30 000
R35 000
R40 000
R45 000
R50 000
Each extended member's cover needs to be equal to or less than the cover of the main member.
Extended Member 8
Gender
Male
Female
Relation
ID number (optional)
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Please provide the correct date of birth as this will determine your premium.
Member Cover
R5 000
R10 000
R15 000
R20 000
R25 000
R30 000
R35 000
R40 000
R45 000
R50 000
Each extended member's cover needs to be equal to or less than the cover of the main member.
save your progress
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Now, let's talk about your beneficiaries
Please let us know who the cover amount need to be paid out to when you pass away. You can select as many beneficiaries as you wish, but the % allocation needs to add up to 100% of the cover amount.
Beneficiary allocation percentage must total 100% to continue.
Beneficiary 1
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Beneficiary Percentage Allocation
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Please advise what % of your cover amount should be allocated to this beneficiary.
Beneficiary 2
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Beneficiary Percentage Allocation
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Please advise what % of your cover amount should be allocated to this beneficiary.
Beneficiary 3
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Beneficiary Percentage Allocation
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Please advise what % of your cover amount should be allocated to this beneficiary.
Beneficiary 4
DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
MONTH 01 02 03 04 05 06 07 08 09 10 11 12
YEAR 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939
Beneficiary Percentage Allocation
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Please advise what % of your cover amount should be allocated to this beneficiary.
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Beneficiary allocation percentage must total 100% to continue.
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Are you going to be paying the monthly premiums?
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Payer Details
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Please provide your Bank Details to debit your account
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plan name
Your Email Adress
This e-mail address will be used in all future communications.
Death benefits for children are subject to restrictions and will be paid out as per below table.
Age at claim event Benefit (irrespective of Benefit Amount)
Below the age of 2
R2,500
2 – 5
R5,000
6 – 13
R10,000
14 – 18
100% of the Total Funeral Benefit
Children up to the age of 21 years may remain on the policy provided they are full time students, attending a registered institution (proof of registration will be required at claims stage.)
Annual cover for children is subject to restrictions and will be paid out as per below table.
Age at claim event Percentage of benefit
Up to the age of 4
50%
4-18
100%
In addition Cover for Children under 6 years of age is limited to R10,000 per annum and Cover for Children between 6 and 14 years of age is limited to R30,000 per annum.
Children up to the age of 21 years may remain on the policy provided they are full time students, attending a registered institution (proof of registration will be required at claims stage.)
Annual increases
The premium will increase annually by 10% and the Cover Amount by 6%. Annual increases occur every 12 months from the start date of your policy.
Annual increases
Premiums and benefits will be reviewed annually and will be increased on 1 January each year. You will be notified of this increase in December of the prior year. Our expectation, assuming claim experience is in line with actuarial assumptions, is that premiums will increase by 10% and benefits will increase by 6% annually.
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Disclosure, disclaimer, authorisation
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Congratulations!
Dear valued client, thank you for completing the application for your
Your monthly
0
Your policy number is:
