Welcome to the standard extended family cover application form. Before you proceed we would like to know if you are under the assistance of an intermediary? If yes please provide us with the names and Code:
Intermediary Surname & initials:
Intermediary Code (Optional):
PROCEED TO FILL THE FORM NOW (consent with terms to proceed)
I consent with the Terms and conditions of Hope Sure Funeral and those of Exodec 229(Pty) Ltd FSP 43212
Street Address City/Town Province Postal Code
Click to proceed to the Next Step
Full Names Surname Gender MaleFemale ID Number or Date of birth Relationship to you
I authorize Hopesure to draw the premiums from my bank account. If the premium changes for any reason in terms of the policy or by agreement between the policyholder and Hopesure the changed premium may likewise be drawn from my bank account. Hopesure may change the day on which it draws the premiums for the preferred day of the month filled in above as described in the "Above you premiums " section in my policy provisions.
Name of Bank Account Number Branch Branch Code Type of Account Please select SavingsCurrentOther The day of the month you prefer the deduction to be made
STEP 4 ADD EXTENDED FAMILY DEPENDENTS
Select the amount of benefit to cover yourself based on your age range (required) Age 18-64 For R80Age 65-74 For R200Age 75-84 For R560
Enter the Names and details of the 1st Extended family member you want to cover
1. Surname Names ID Number/Date of Birth Relationship to you Gender MaleFemale Country of residence Republic of South AfricaLesothoKingdom of EswatiniBotswanaNamibiaZimbabweMozambique
Select the benefit that applies to the 1st extended family members you want to cover (required) Age 00-22 For R30Age 23-65 For R100Age 66-75 For R285Age 76-84 For R580
ADD ANOTHER EXTENDED FAMILY DEPENDENTNOYES
Enter the Names and details of the 2nd Extended family member you want to cover
2. Surname Names ID Number/Date of Birth Relationship to you Gender MaleFemale Country of residence Republic of South AfricaLesothoKingdom of EswatiniBotswanaNamibiaZimbabweMozambique
Select the benefit that applies to the 2nd extended family members you want to cover (required) Age 00-22 For R30Age 23-65 For R100Age 66-75 For R285Age 76-84 For R580
Enter the Names and details of the 3rd Extended family member you want to cover
3. Surname Names ID Number/Date of Birth Relationship to you Gender MaleFemale Country of residence Republic of South AfricaLesothoKingdom of EswatiniBotswanaNamibiaZimbabweMozambique
Select the benefit that applies to the 3rd extended family members you want to cover (required) Age 00-22 For R30Age 23-65 For R100Age 66-75 For R285Age 76-84 For R580
Enter the Names and details of the 4th Extended family member you want to cover
4. Surname Names ID Number/Date of Birth Relationship to you Gender MaleFemale Country of residence Republic of South AfricaLesothoKingdom of EswatiniBotswanaNamibiaZimbabweMozambique
Age 00-22 For R30Age 23-65 For R100Age 66-75 For R285Age 76-84 For R580
Enter the Names and details of the 5th Extended family member you want to cover
5. Surname Names ID Number/Date of Birth Relationship to you Gender MaleFemale Country of residence Republic of South AfricaLesothoKingdom of EswatiniBotswanaNamibiaZimbabweMozambique Age 00-22 For R30Age 23-65 For R100Age 66-75 For R285Age 76-84 For R580
Enter the Names and details of the 6th Extended family member you want to cover
6. Surname Names ID Number/Date of Birth Relationship to you Gender MaleFemale Country of residence Republic of South AfricaLesothoKingdom of EswatiniBotswanaNamibiaZimbabweMozambique Age 00-22 For R30Age 23-65 For R100Age 66-75 For R285Age 76-84 For R580
Enter the Names and details of the 7th Extended family member you want to cover
7. Surname Names ID Number/Date of Birth Relationship to you Gender MaleFemale Country of residence Republic of South AfricaLesothoKingdom of EswatiniBotswanaNamibiaZimbabweMozambique Age 00-22 For R30Age 23-65 For R100Age 66-75 For R285Age 76-84 For R580
YOUR TOTAL MONTHLY PREMIUM (Inclusive of the all the dependents you have covered) AMOUNT IN RAND (required) $0
The information I have entered is accurate and I consent to the general terms and conditions of hope sure funeral covers plans.