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Ll F

u a

uneral

ervices

Address: 3 Blombos close, Plattekloof , Cape Town TEL: 076 170 4008 / 082 221 9971/ 021 939 3907 email:
lulafuneral@gmail.com

MEMBERSHIP APPLICATION FORM:

Underwritten by:

POLICYHOLDER DETAILS
Surname.First Name(s).
TitleI.D. Number...Date of Birth..
Residential

Address...Code...

Telephone No.: HOME ()....WORK ().....CELL..


Package

Cash

Monthly Premium: R..

DEPENDENTS
FULL NAMES (SURNAME FIRST)

I.D. NUMBER

RELATIONSHIP

1.

Spouse

2.

Child

3.

Child

4.

Child

5.

Child

6.

Child

7.

Child

EXTENDED FAMILY DETAILS


FULL NAMES (SURNAME FIRST)

COVER

PREMIUM

1.

I.D. NUMBER

RELATIONSHIP

2.

3.

4.

R
TOTAL

BENEFICIARY
Title

Full Names

Date of Birth

I.D. Number

Relationship

..

DEBIT ORDER DETAILS


Account Name.Account TypeAccount Number..
Bank NameBranch Name..Branch Code..
Commencement Date..Monthly Debit Order Date
Bank: Branch Type of Account: ..../Savings........./Cheque
Account Name: Account No: ..
I hereby authorise African Unity Insurance (AUI) to draw against my account with the abovementioned bank (or any other bank or branch to which I may
transfer my account) the amount necessary for payment of the monthly Premium due in respect of this Funeral Insurance Policy. All such withdrawals from
my Bank account for this purpose shall be treated as though they had been signed by me personally. Should my account fall in arrears, I authorise AUI to
increase my monthly Premium to cover the arrears within the contract period. I understand that the withdrawal hereby authorised will be processed by
computer through a system known as Bank-serve or any other electronic means and I understand that details of which will be printed on my Bank Statement
or an accompanying voucher. I agree to pay any and all bank charges that relate to this debt order including, without derogating from the general hereof, all
lodgement, failure and other costs that AUI may incur.
Receipt of this instruction by AUI shall be regarded as receipt thereof by my Bank.
DECLARATION
I declare that the information supplied above is to the best of my knowledge true, complete and correct. I also confirm that the Rules, Terms and Conditions
stated on the reverse side of this page have been explained to me and are hereby accepted.

..
Account Holders Signature

..

Policyholders Signature

Date

TERMS AND CONDITIONS:


Mtengwane Funeral Directors (Pty) Ltd with registration number: 2015/062272/07 will provide Burial Fund to its active members provided the member
complies with terms and conditions stated below.
To Be an Active Member you must:

Fill out the Product Application Form clearly with all required information and Sign

Provide certified copies of all required documents; like: IDs & Birth Certificates

Pay your premiums every month and keep all your receipts in safe place. Your policy will lapse after 45 days from date of last payment if no
premium (s) were paid the policy will lapse and a new waiting period of 6 (six) months will apply.

You will be allocated with Easy Pay reference so you can pay at any Pep Stores, Spar, Shoprite, Post Office, Pick N Pay, Checkers, Boxer Stores,
etc . Keep this card as it will make your life easier.

You must not engage on risk activities like suicide, committing crime, etc. as this will affect your claim

Waiting Period:

Waiting Period means the Waiting Period as set out in the scheme rules of the Client at inception and shall not be less than:

6 Months of continuous cover for all new members joining the Client after the commencement date of this contract.

24 Months of continuous cover in respect of death due to suicide or attempted suicide.

Accidental death will be covered as from receipt of the first months premium by Mtengwane Funeral Directors.

CLAIM PROCEDURE
The following documents relating to the Assured Lifes death must be provided to AFRICAN UNITY by the client:

The official claim form as required by the Insurer;

Certified copy of the original death certificate of the Assured Life;

Certified proof of identity of the Assured Life;

Complete BI 1663

An official police report in the case of Accidental Death of the Assured Life;

A medical report in the case of stillborn babies, indicating that the pregnancy reached the 26th (TWENTY SIXTH) week; and

Any such other documentary proof as may be required by the Insurer in the sole discretion of the Insurer.

Claims may only be repudiated by the insurer.

No claims of whatsoever nature instituted in terms of this Master Policy shall be entertained after the date of cancellation of this Master Policy, unless the
insured event occurred prior to the date of cancellation.

BENEFITS OF THE CLIENT

All benefits of the client will be distributed as stated on the policy contact.

All funeral benefits will only be claimed by a nominated beneficiary.

NO PREMIUM = NO COVER

IMPORTANT WARNING
Products or Transactions chosen by him meets his needs and requirements. To this end, it is proposed that the Applicant engages the Intermediary or insurer
with regard to the impact of the proposed transaction on his finances, other insurance and insurance Policies or broader investment portfolio. The Applicant
is advised to complete and sign all requisite forms after ensuring that he understands the content thereof. The Applicant is invited to request information, of
any nature whatsoever, whether verbal or written, relative to this Policy. Any concerns regarding the product sold may be addressed to either the long term
insurance Ombudsman or the Registrar of Long term Insurance, whose details are set out below, if the Applicant has concerns regarding the products sold
and/or advice given to him.
DETAILS OF THE UNDERWRITER
ZINMAR CORPORATE CONSULTANTS
appoints:

DETAILS
OF
THE
SERVICES PROVIDER

FINANCIAL

ZINMAR CORPORATE ONSULTANTS


52 18th AveNUE

DETAILS OF THE OMBUDSMAN


Ombudsman
Insurance

for

long

term

DETAILS
OF
SERVICES BOARD

FINANCIAL

Financial Services Provider

AFRICAN UNITY INSURANCE as the


Private Bag X45, Claremont,
P.O. Box 35655, Menlo Park, 0102
SCHEME
DETAILS
(For Official
completion
only)
appointed
UNDERWRITER
of their Policy
Boston,
Bellville, 7535
7735
Tel no: 012-428 8000
the Lula Burial Services
Tel no: 021 949 6021
Tel no: 021-657 5000
Name:
________________________________________________________
Agent Code: ____________________________________
Fax no: 012-347 0221
WithAgent
offices
at: Riesling
House, Dorp
Email: Zinmar@new.co.za
Fax no: 021-674 0951
Street, Vineyard Office Estate, Bellville
Website: www.fsb.co.za
Member
Member No: ____________________________________
7530,
Tel no: Name:
021-913______________________________________________________
9240
Authorised Financial Services Provider
Website: www.ombud.co.za
Email:
Code
info@africanunity.co.za
Choice
Member Signature: _______________________________
FSP 14286

: Funeral IPlan
DECLARATION:
the undersigned
herebyBenefit
declare that
have000
read and understand the terms and
conditions
1: Death Basic
: IR10
Funeral
Plan above.
2: Death Basic Benefit:

R40

per family

R35

R 7 500

per extended member

Signature of Applicant_________________________________________________________________ Date: ______________________________________ 201____