Hidden
Referral Code
Personal Details
Name
Surname
ID Number
Age
Marital Status
Please select
Single
Married
Divorced
Widow / Widower
Gender
Please select
Male
Female
Cell No
Email Address
Copy of ID
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Select files
Max. file size: 16 MB.
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Funeral Plan Details
Would you like Single Cover (just yourself) or Family Cover (yourself & dependants)?
Please select
Single Cover
Family Cover
Single Member Cover Options
Please select
Option 1 - R10000 Cover - R70.00pm
Option 2 - R20000 Cover - R95.00pm
Option 3 - R30000 Cover - R120.00pm
Family Cover Options
Please select
Option 1 - Main Member 18-65 (R10000), Partner 18-65 (R10000), Child 14-20 (R10000), Child 6-13 (R5000), Child Stillborn-5 (R2500) - R80.00pm
Option 2 - Main Member 18-65 (R20000), Partner 18-65 (R20000), Child 14-20 (R20000), Child 6-13 (R10000), Child Stillborn-5 (R5000) - R115.00pm
Option 3 - Main Member 18-65 (R30000), Partner 18-65 (R30000), Child 14-20 (R30000), Child 6-13 (R15000), Child Stillborn-5 (R7500) - R150.00pm
Dependants
Name
Surname
Date of Birth
Gender
Relationship
Actions
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Delete
There are no
Dependants.
Add Dependant
Maximum number of dependants reached.
Extended Family
Would you like to add Extended Family?
Please Select
Yes
No
Extended Family | 18-65 Years
Relationship
Surname
Initials
Date of Birth
Product Name
Actions
Edit
Delete
There are no
Members.
Add Member
Maximum number of members reached.
Extended Family | 66-75 Years
Relationship
Surname
Initials
Date of Birth
Product Name
Actions
Edit
Delete
There are no
Members.
Add Member
Maximum number of members reached.
Extended Family | 76-85 Years
Relationship
Surname
Initials
Date of Birth
Product Name
Actions
Edit
Delete
There are no
Members.
Add Member
Maximum number of members reached.
Nominated Beneficiary
Relationship
Name
Surname
ID Number
Nominated Beneficiary Copy of ID
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Select files
Max. file size: 16 MB.
Premium Costs
Extended Family (18 - 65 years) Premium
Price:
R0.00
Extended Family (66 - 75 years) Premium
Price:
R0.00
Extended Family (76 - 85 years) Premium
Price:
R0.00
Total Premium Payable
Deduction Authority
Name of Bank
(Required)
Branch
(Required)
Branch Code
(Required)
Account No
(Required)
Type of Account
(Required)
Cheque
Transmission
Savings
Name of Account Holder
(Required)
Premium Deduction Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Deduction Authority
(Required)
I agree to the monthly deduction
I hereby authorise Infussion to affect the soonest monthly deduction of the Grand Total (current and/or arrears including amendments that may be made in terms of master policy) and an annual increase if applicable from my salary, current bank account or any future bank account I might have, and to continue such deductions until written notice of cancellation is received.
Signature
(Required)
