Affiliated with Assupol Step 1 of 11 - Select an option 9% Who would you like to get funeral cover for Myself My Spouse and Children My Parents & In-laws Other Dependants & Children over 21 Add your own funeral cover Only one main member can be added. Main Member (For Yourself) Name Date of Birth Age Choose Cover Amount Monthly Premium Actions Edit Delete There are no Main Member. Add Myself Maximum number of main member reached. Main MemberGrand Total Add your Spouse and Children under age 21Spouse and children under 21 Relationship Name Age Date of Birth Choose Cover Amount Monthly Premium Actions Edit Delete There are no Spouse and children under 21. Add Spouse and children under 21 Maximum number of spouse and children under 21 reached. Total for Spouse and children under 21Grand Total Please add your Parents and In-laws belowFor Parents & Parents-in-law Relationship Name Age Date of Birth Choose Cover Amount Monthly Premium Actions Edit Delete There are no Parents & In-laws. Add Parents & In-laws Maximum number of parents & in-laws reached. Total for Parents & Parents-in-lawGrand Total Other Dependants & Children over 21Other Dependants & Children over 21 Name Age Date of Birth Choose Cover Amount Monthly Premium Actions Edit Delete There are no Dependants & Children over 21. Add Dependant or Child over 21 Maximum number of dependants & children over 21 reached. Total for Other Dependants & Children over 21Grand Total Summary of your chosen benefits:Main Member {Nested Form:5:filter[26,9,31]}Spouse & Children Under 21 {Nested Form:1:filter[28,26,9,29]}Parents & In-laws {Nested Form:3:filter[28,26,9,29]}Other Dependants & Children Over 21 {Nested Form:51:filter[28,26,9,30]}Grand TotalFree Benefits included in your premium: - Cover for stillborn children, and for newborn children for their first three months - Instant accidental death cover of R5 000 for all lives insured from acceptance date to the start of the policy - Premium Waiver - Death – guaranteed insurance for your family, without them having to pay any premiums for five years after your death - Assupol On-Call: Tutor assistance to children, Trauma counselling & Transport of the deceased & Family to the place of the funeral If you are satisfied with your chosen cover and the total premium, click “next” to continue with an official online application. About YouFull Name(Required) Full First Name Surname ID Number(Required)Your 13 Digit ID NumberMarital StatusSingleMariedDivorcedWidowedEducation(Required)No MatricMatricDiplomaDegreeHome Language(Required)EnglishAfrikaansisiNdebeleisiXhosaisiZuluSesotho Sotho-TswanaSesotho sa Leboa (Sepedi)SetswanasiSwatiTshivendaXitsongaEthnic group(Required)BlackColouredIndianWhiteOther About Your BeneficiaryNominate Estate?(Required) Yes No The family member you appoint to claim & receive the policy benefits, should you pass away. (Must be age 18 or older)Full First Names(Required)Surname(Required)Initials(Required)Relationship to you(Required)SpouseSon (Age under 21)Daughter (Age under 21)Son (Age 21 +)Daughter (Age 21 +)BrotherSisterGrandfatherGrandmotherGrandchildUncleAuntNephew (son of brother or sister)Niece (daughter of brother or sister)Cousin (child of uncle or aunt)Second Cousin (child of cousin)Brother-in-LawSister-in-LawSon-in-LawDaughter-in-LawLife PartnerSecond SpouseFatherMotherTitle(Required)MrMsMrsMissDrProffGender(Required)MaleFemaleDate of Birth(Required) DD slash MM slash YYYY Cellphone(Required) Your Bank DetailsName of Bank(Required)Account Number(Required)Branch NameBranch CodeAccount Type(Required)CurrentSavingsTransmissionPreferred start date (i.e.: 1st premium deduction date) DD slash MM slash YYYY Your Contact DetailsTel (Home)Cellphone(Required)Email(Required) Address(Required) Street Address City Province ZIP / Postal Code Postal Address(Required)Postal address is the same as street address Yes No Postal Address P.O.Box Number and Suburb City or Town Province Postal Code Your Employment DetailsName Of Employer(Required)Main Occupation(Required)Work CellphoneWork TelephoneWork E-mail Gross Monthly Income:(Required)Less than R 6000R 6 000 - R 12 999R 13 000 - R 24 999R 25 000 or moreEmployment Sector(Required)ParastatalGovernmentPrivate CompanySelf EmployedInformal SectorPersal Number(Required)
