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

    STEP 1 APPLICANT PERSONAL DETAILS
    Title First Name Surname
    ID Number Gender MaleFemale
    Cell Tel (work)
    Email (Optional)

    Street Address
    City/Town Province Postal Code

    Click to proceed to the Next Step

    STEP 2 ADD NOMINATED BENEFICIARY

    Full Names
    Surname Gender MaleFemale
    ID Number or Date of birth Relationship to you

    Click to proceed to the Next Step

    STEP 3 PAYMENT OF BANK DEBIT ORDER

    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

    Click to proceed to the Next Step

    STEP 4 ADD EXTENDED FAMILY DEPENDENTS

    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 Country of residence

    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 Country of residence

    ADD ANOTHER EXTENDED FAMILY DEPENDENTNOYES

    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 Country of residence

    ADD ANOTHER EXTENDED FAMILY DEPENDENTNOYES

    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 Country of residence

    ADD ANOTHER EXTENDED FAMILY DEPENDENTNOYES

    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 Country of residence

    ADD ANOTHER EXTENDED FAMILY DEPENDENTNOYES

    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 Country of residence

    ADD ANOTHER EXTENDED FAMILY DEPENDENTNOYES

    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 Country of residence

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