EB SOLUTIONS FUNERAL SCHEME
INDIVIDUAL DEBIT ORDER APPLICATION FORM

Underwritten by Constantia Life & Health Assurance Company Limited, Registration Number 1952/001635/06, (The Insurer)

THE MASTER POLICY ISSUED IS THE SOURCE OF ALL BENEFITS, RIGHTS, AND OBLIGATIONS AND EXCLUSIONS. TO DETERMINE YOUR INDIVIDUAL NEEDS, WE SUGGEST THAT YOU CONTACT YOUR BROKER AND REQUEST ADVICE FROM HIM / HER.

Application

BROKER DETAILS

PRODUCT SUMMARY

FAMILY FUNERAL COVER PROVIDES LUMP SUM ON THE DEATH OF THE PRINCIPAL MEMBER AND THE DEFINED AND REGISTERED DEPENDANTS. A LUMP SUM BENEFIT IF DEATH AS A RESULT OF AN ACCIDENT. OTHER BENEFITS INCLUDE PREMIUM WAIVER, TRAUMA COUNSELLING, REPATRIATION.
OPTION 1 (R 26.50 PER FAMILY PER MONTH) OPTION 2 (R 52.50 PER FAMILY PER MONTH) OPTION 3 (R 78.50 PER FAMILY PER MONTH)
LIMITED TO R10,000 LIMITED TO R20,000 LIMITED TO R30,000
FAMILY FUNERAL COVER ON THE DEATH OF EXTENDED FAMILY DEPENDANTS (Parents / Parent in Law / Siblings / Adult child).
An additional premium will apply for each extended family dependant.

PRODUCT SELECTION

PREMIUM PER FAMILY (incl. VAT)
SELECT OPTION BY INDICATING NUMBER OF DEPENDANTS TO ADD ADDITIONAL PREMIUM FOR EXTENDED FAMILY DEPENDANT
R 17.00 PER EXTENDED FAMILY DEPENDANT
R 34.00 PER EXTENDED FAMILY DEPENDANT
R 51.00 PER EXTENDED FAMILY DEPENDANT
R 32.50 PER EXTENDED FAMILY DEPENDANT
R 32.50 PER EXTENDED FAMILY DEPENDANT
R 32.50 PER EXTENDED FAMILY DEPENDANT

PERSONAL PARTICULARS

APPLICANT

CONTACT DETAILS

City
State/Province
Zip/Postal
City
State/Province
Zip/Postal

DEPENDANTS To see who qualifies as a dependant see DECLARATION b)

EXTENDED FAMILY (To see who qualifies as a dependant see DECLARATION b)

BENEFICIARY

PREMIUM PAYMENT

DEBIT ORDER DETAILS
PLEASE NOTE THAT PREMIUMS ARE COLLECTED IN ADVANCE ON THE 1ST OF EACH MONTH*
Having applied for the above mentioned Funeral Policy and on acceptance of my application by the Insurer, I hereby authorise the Insurer or its representative to debit my account, the premiums payable under the above plan on the first day of each month in accordance with the Debit Order System. Such authorisation shall remain in force and effect until cancelled by myself, in writing with one calendar months notice. I further authorise The Insurer to increase the amount due in terms of the policy from time to time and authorise my bank to effect payment on relevant increases. Notwithstanding the fact that I grant the Insurer permission to collect premiums, I acknowledge that I need to ensure that premiums are collected for cover to remain in force.

DECLARATION*

I declare that I have not withheld any information and I accept that this application and declaration shall be the basis of the contract of insurance between me and the Insurer, which will become effective on the first day of the month for which premiums are received. I also acknowledge that I have requested and instructed the broker not to complete a financial needs analysis. Furthermore, I understand and accept that this instruction not to proceed with a full financial needs analysis could have the effect that all my financial needs may not be properly addressed.
I further confirm that the following notable conditions have been explained to me:
a) A general 6 month waiting period is to apply from date of inception for all non-accident related death.
b) Not all your dependants on your family funeral cover are automatically covered under this policy, only your eligible spouse and your eligible children are covered as per the policy definitions.
i. Only one spouse is allowed.
ii. The maximum age for a child dependant is under 21 years. This age may be extended to twenty six (26) in respect of an unmarried child who is a
dependant on the Principal Insured Person’s policy and is financially dependent on the Principal Insured Person.
iii. Cover is provided for extended family members at an additional premium per extended family member. Extended family dependants must be parent or parent in law or a sibling or an adult child. The age limit is 75 (age attained) on entry.
I confirm that although I have completed this application form, it does not constitute an insurance contract until a membership number is assigned, policy issued and premium is successfully paid.