Hopesure

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 STANDARD PLAN

-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.


    Are you under the assistance of a sales representative ? If yes please provide us with the names and Code:
    Sales Representative Surname & Names:
    Sales Representative 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 PLAN AND ADD FAMILY DEPENDENTS

    Please select the plan that you need Single PersonMember and SpouseMember and 5 childrenFamily CoverExtended Family Cover

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

    Select the benefit that applies to the first single person you want to cover
    Single Person 18 - 64 years Single Person 65 - 74 years
    Single Person 75 - 84 years Single Person 85 - 95 years

    Click (+) to Add another person and (-) to remove.

    Select the benefit that applies to you and your spouse
    Member and Spouse 18 - 64 years Member and Spouse 65 - 74 years
    Member and Spouse 75 - 84 years Member and Spouse 85 - 95 years

    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

    Select the benefit that applies to you and your children ( Covers up to 5 children)
    Member and Children 18 - 64 years Member and Children 65 - 74 years
    Member and Children 75 - 84 years Member and Children 85 - 95 years

    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

    Select the benefit that applies to your family ( Covers you, your spouse and up to 5 children)
    Family Cover 18 - 64 years Family Cover 65 - 74 years
    Family Cover 75 - 84 years Family Cover 85 - 95 years

    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

    Select the benefit that applies to your extended family members you want to cover
    Extended family cover 00 - 22 years
    Extended family cover 23 - <65 years
    Extended family cover 66 - 75 years
    Extended family cover 76 - 84 years
    Extended family cover 85 - 95 years

    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

    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 Africa Unity FSP No 43066.

    “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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