7 Nettie Street, Flamewood, Klerksdorp

Tel: 018 462 1053, Fax: 086 560 5541

E-mail:  info@hopesurefuneral.co.za

FSP: 46295

APPLICATION FOR MEMBERSHIP TO THE 1+5/9/13

-ABOUT THE APPLICATION FORM-

This application form constitutes four simple steps about your details and those of the dependents you want to cover. By proceeding to complete the form you are in agreement with the terms and conditions of hope sure funeral. We comprehend how imperative your privacy is and will protect your personal information.


Terms and conditions

    Are you under the assistance of an intermediary ? If yes please provide us with the names and the intermediary Code:
    Intermediary Surname & Names:
    Intermediary Code (Optional):

    PROCEED TO FILL THE FORM NOW (consent with terms to proceed)

    I consent with the Terms and conditions

    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 CHOOSE BENEFIT AND MONTHLY PREMIUMS AND ADD FAMILY DEPENDENTS

    Please provide the details of the persons you want to cover.
    How many people do you want to cover?

    What is the age of the oldest person you want to cover?Less than 65 yearsBetween 65 and less than 70 yearsBetween 70 and less than 75 yearsBetween 75 and less than 80 yearsBetween 80 and less than 85 years

    Choose benefit
    Choose benefit
    Choose benefit
    Choose benefit
    Choose benefit

    1. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    2. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    3. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    4. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    5. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    What is the age of the oldest person you want to cover?Less than 65 yearsBetween 65 and less than 70 yearsBetween 70 and less than 75 yearsBetween 75 and less than 80 yearsBetween 80 and less than 85 years

    Choose benefit
    Choose benefit
    Choose benefit
    Choose benefit
    Choose benefit

    1. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    2. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    3. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    4. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    5. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    6. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    7. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    8. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence
    Please read the general terms and conditions below

    9. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence
    Please read the general terms and conditions below

    What is the age of the oldest person you want to cover?Less than 65 yearsBetween 65 and less than 70 yearsBetween 70 and less than 75 years

    Choose benefit
    Choose benefit
    Choose benefit

    1. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    2. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    3. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    4. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    5. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    6. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    7. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    8. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence
    Please read the general terms and conditions below

    9. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence
    Please read the general terms and conditions below

    10. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    11. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    12. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    13. Surname Names ID Number/Date of Birth
    Relationship to you Gender Country of residence

    Administration: Exodec 229 (Pty) Ltd FSP 43212 Email: info@exodecgroup.co.za Fax: 086 608 7594 Compliance: Leona Prinsloo Co4920 Email: lprinsloo@mweb.co.za Fax: 088 012 664 6257 Fees disclosure: 50% Risk premium. 2% Binder Fee, 16% admin, 16% marketing, 16 operational This product is underwritten by Constantia Life & Health Assurance Company Limited A registered Long -term insurer and authorized financial services provider (FSP Number: 49986)

    “Our payment methods also include”

    This method allows you to make use of the swipe method where you only need to swipe your bank card once and the payment will be set for the month following. please ask your representative or contact the office helpline to explain how you can make use of this payment method.

    Easy pay allows you to pay cash at selected local stores such as shoprite, woolworths, boxer,etc. you will receive an easypay number which to use when making payments. please ask your represntative or contact the office helpline should you have queries on this behalf.

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