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Funeral Cover

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Applicant Details
Title*
Initials*
Surname*
Full Names*
Gender*
Maiden Name*
Marital Status*
Nationality*
Date of Birth*
ID Number*
Residential Address*
Street AddressZIP / Postal Code
Postal Address
Street AddressZIP / Postal Code
Work Telephone Number*
Home Telephone Number
Cell Number*
Email Address*
Spouse Details
Title*
Initials*
Surname*
Full Names*
Maiden Name*
Date of Birth*
Gender*
ID Number*
Contact Number*
Email*
Children Details
I have*
Surname*
First Name*
Gender*
- Male
- Female
Date of Birth*
Second Child Details
Surname*
First Name*
Gender*
- Male
- Female
Date of Birth*
Third Child Details
Surname*
First Name*
Gender*
- Male
- Female
Date of Birth*
Fourth Child Details
Surname*
First Name*
Gender*
- Male
- Female
Date of Birth*
Fifth Child Details
Surname*
First Name*
Gender*
- Male
- Female
Date of Birth*
Sixth Child Details
Surname*
Gender*
- Male
- Female
Date of Birth*
Beneficiary Details
Title*
Initials*
Surname*
First Names*
Date of Birth*
Gender*
- Male
- Female
Relationship*
Contact Number*
Funeral Plan - Parents Details
I would like to cover*
First Names*
Surname*
Date of Birth*
ID Number*
Relationship*
Cover*
Second Parent Details
First Names*
Surname*
Date of Birth*
ID Number*
Relationship*
Cover*
Third Parent Details
First Names*
Surname*
Date of Birth*
ID Number*
Relationship*
Cover*
Fourth Parent Details
First Names*
Surname*
Date of Birth*
ID Number*
Relationship*
Cover*
Funeral Plan - Extended Family Details
I would like to cover*
First Names*
Surname*
Date of Birth*
ID Number*
Relationship*
Cover*
Second Extended Family Member Details
First Names*
Surname*
Date of Birth*
ID Number*
Relationship*
Cover*
Third Extended Family Member Details
First Names*
Surname*
Date of Birth*
ID Number*
Relationship*
Cover*
Fourth Extended Family Member Details
First Names*
Surname*
Date of Birth*
ID Number*
Relationship*
Cover*
I have read, understood and accept the Terms and Conditions and Statutory Notice set out below*
- Yes, I have read, understood and accept the Terms and Conditions and Statutory Notice
Policy T's & C's Policy T's & C's - Statutory Notice

Deduction by*
- Debit Order
- Organisation
- Cash
Debit Order
Account Holder Name*
Bank*
Please specify your bank*
Branch*
Branch Code*
Account Type*
- Cheque/Current
- Savings
- Transmission
Account Number*
Date of Debit Order
Organisation
Occupation*
Employer*
Tel:*
Employer Physical Address*
Street AddressCityState / Province / RegionZIP / Postal CodeCountry
Employment Start Date*
Employee Number
Employment Type*
Collection Agent
Collection Agent Name
Do you agree to the above and acknowledge that all payments made to your agent, will only be recognised by Evolusure upon receipt into the EvoluSure Premium bank account?*
- Yes, I agree
PREMIUM
I hereby authorise Evolusure to issue and deliver payment instructions to my Employer for collection against my salary on condition that the sum of such payment instructions will never exceed my obligations as agreed to in the Agreement, and commencing on and continuing until this Authority and mandate is terminated by me by giving you notice in writing of not less than 20 ordinary working days. In the event that the payment day falls on a Saturday , Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. I understand that the deduction hereby authorised will be processed through a salary deduction system provided by my Employer and I also understand that details of each deduction will be printed on my salary advice. Such must contain a number, which number must be included in the said payment instruction and if provided to you should enable you to identify the Agreement.
Do you agree to the above and acknowledge that all payment instructions issued by Evolusure shall be treated by your above mentioned Employer as if the instructions had been issued by you personally?*
- Yes, I agree

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Evolusure

EvoluSure Address

Alenti Office Park

Block A 457, Witherite Road,

Cnr Witherite and Botterklapper Street,

The Willows, Pretoria East

CONTACT US

+27 81 350 2530

info@evolusure.co.za

www.evolusure.co.za

Funeral Cover

Applicant Details

Spouse Details

Children Details

Second Child Details

Third Child Details

Fourth Child Details

Fifth Child Details

Sixth Child Details

Beneficiary Details

Funeral Plan - Parents Details

Second Parent Details

Third Parent Details

Fourth Parent Details

Funeral Plan - Extended Family Details

Second Extended Family Member Details

Third Extended Family Member Details

Fourth Extended Family Member Details

Debit Order

Organisation

Collection Agent