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) :
STEP 4 CHOOSE PLAN AND ADD FAMILY DEPENDENTS
Please select the plan that you need Single Person Member and Spouse Member and 5 children Family Cover Extended Family Cover
Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
Select the benefit that applies to the first single person you want to cover Single Person 18 - 64 years R 5,000 for R 21 PM R 10,000 for R 42 PM R 15,000 for R 70 PM R 20,000 for R 80 PM R 25,000 for R 110 PM Single Person 65 - 74 years R 5,000 for R 60 PM R 10,000 for R 120 PM R 15,000 for R 150 PM R 20,000 for R 200 PM R 25,000 for R 330 PM Single Person 75 - 84 years R 5,000 for R 135 PM R 10,000 for R 270 PM R 15,000 for R 430 PM R 20,000 for R 560 PM R 25,000 for R 700 PM Single Person 85 - 95 years R 5,000 for R 180 PM R 10,000 for R 360 PM
Click (+) to Add another person and (-) to remove. - +
Select the benefit that applies to you and your spouse Member and Spouse 18 - 64 years R 5,000 for R 40 PM R 10,000 for R 80 PM R 15,000 for R 110 PM R 20,000 for R 140 PM R 25,000 for R 170 PM Member and Spouse 65 - 74 years R 5,000 for R 110 PM R 10,000 for R 220 PM R 15,000 for R 320 PM R 20,000 for R 410 PM R 25,000 for R 510 PM Member and Spouse 75 - 84 years R 5,000 for R 200 PM R 10,000 for R 400 PM R 15,000 for R 580 PM R 20,000 for R 760 PM R 25,000 for R 930 PM Member and Spouse 85 - 95 years R 5,000 for R 280 PM R 10,000 for R 560 PM
1. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
2. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
Select the benefit that applies to you and your children ( Covers up to 5 children) Member and Children 18 - 64 years R 5,000 for R 25 PM R 10,000 for R 50 PM R 15,000 for R 80 PM R 20,000 for R 100 PM R 25,000 for R 130 PM Member and Children 65 - 74 years R 5,000 for R 80 PM R 10,000 for R 160 PM R 15,000 for R 240 PM R 20,000 for R 300 PM R 25,000 for R 390 PM Member and Children 75 - 84 years R 5,000 for R 175 PM R 10,000 for R 350 PM R 15,000 for R 500 PM R 20,000 for R 660 PM R 25,000 for R 810 PM Member and Children 85 - 95 years R 5,000 for R 240 PM R 10,000 for R 480 PM
1. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
2. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
3. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
4. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
5. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
6. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
Select the benefit that applies to your family ( Covers you, your spouse and up to 5 children) Family Cover 18 - 64 yearsR 5,000 for R 45 PM R 10,000 for R 90 PM R 15,000 for R 120 PM R 20,000 for R 160 PM R 25,000 for R 200 PM Family Cover 65 - 74 yearsR 5,000 for R 120 PM R 10,000 for R 240 PM R 15,000 for R 340 PM R 20,000 for R 450 PM R 25,000 for R 560 PM Family Cover 75 - 84 yearsR 5,000 for R 235 PM R 10,000 for R 470 PM R 15,000 for R 660 PM R 20,000 for R 890 PM R 25,000 for R 1100 PM Family Cover 85 - 95 yearsR 5,000 for R 330 PM R 10,000 for R 660 PM
1. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
2. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
3. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
4. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
5. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
6. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
7. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
Select the benefit that applies to your extended family members you want to cover Extended family cover 00 - 22 years R 5,000 for R 10 PM R 10,000 for R 15 PM R 15,000 for R 20 PM R 20,000 for R 30 PM Extended family cover 23 - <65 years R 5,000 for R 30 PM R 10,000 for R 55 PM R 15,000 for R 75 PM R 20,000 for R 100 PM Extended family cover 66 - 75 years R 5,000 for R 80 PM R 10,000 for R 145 PM R 15,000 for R 210 PM R 20,000 for R 285 PM Extended family cover 76 - 84 years R 5,000 for R 180 PM R 10,000 for R 300 PM R 15,000 for R 345 PM R 20,000 for R 580 PM Extended family cover 85 - 95 years R 5,000 for R 210 PM R 10,000 for R 400 PM
1. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
2. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
3. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
4. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
5. Surname Names ID Number/Date of Birth Relationship to you Gender Male Female Country of residence Republic of South Africa Lesotho Kingdom of Eswatini Botswana Namibia Zimbabwe Mozambique
The information I have entered is accurate and I consent to the general terms and conditions of hope sure funeral covers plans.