The standard plan family cover allows you to cover yourself, your spouse and up to five children

STANDARD PLAN FAMILY COVER APPLICATION FORM

    Welcome to the standard 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 FAMILY DEPENDENTS

    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

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