info@mr21.co.za
Send us an Email
015 151 0251/2
Give us a call
Step 1: Premium Payer / Proposer Details
First Names:
Surname:
SA ID/Passport:
Cell Number:
Telephone (W):
Postal Address:
Postal Code:
Email Address:
Relationship to Principal Member: (only if different from Premium payer)
Other:
Step 2: Principal member details
Title:
First Names:
Surname:
Gender
SA ID/Passport:
Maritial Status
Other:
Cell number:
Telephone:
Full Address
STEP 3: Spouse details
Name
Surname
Identity Number
Children's details
Name
Surname
Identity Number
Child 2
Name
Surname
Identity Number
Child 3
Name
Surname
Identity Number
Child 4
Name
Surname
Identity Number
Extended families and wider children of the principal member
First names
Surname
Identity No.
Relationship
Cover
Premium
Beneficiary Nomination
I hereby nominate the following person, who is my dependent or nominee, for any benefits due to be paid in the event of my death.
First Names:
Surname:
Identity No/Passport:
Relationship:
Payment Details
Mode of payment:
Frequency:
Policy Commencement date:
Funeral Plan
Family Cover
Total Extended Family and Wider Children Cover
Total Premium
Bank Details:
Name of Bank:
Name of Account Holder:
Account Number:
Branch:
Branch Code:
Account Type:
Debit order day
Debit order deduction authority (Applicable to debit order payment only) I hereby authorise MR21 Funerals to commence a debit order withdrawal from my account on the debit day selected and monthly thereafter, with a possible percentage increase each year, for premium applicable for the cover selected. I understand that the debit order will be run on the date selected; if for whatever reason it is not honoured, 2(two) withdrawal runs will be submitted the next month. In the event of this run not being dishonoured, the policy will lapse, subject to the grace period as stipulated under the terms and conditions. No cash payments are acceptable for arrear or any other premiums. I understand that this signed document is required in MR21 Funerals offices 10 (ten) working days prior to the elected deduction date; if not, the deduction will only qualify for the following calendar month’s deductions, and cover will only commence the following month.
Terms and conditions
Funeral/Cash Cover: 1. There is no joining fee. 2. Cash benet. 3. The main member’s minimum joining age is 18 and the maximum joining age is 74. 4. Waiting period = 6 months for a member, 1 month for accidental death and 24 months for suicide related deaths. 5. The waiting period for members above 74 years is 12 months. 6. Premiums on all policies must be honoured. Failure to do so lapses the policy without notice. 7. Claims must be made within six months after death, however you must notify us of the death immediately. Burial/Services Cover: 1. There is no joining fee. 2. Services will be rendered with no cash payment. 3. Waiting period = 6 months for a member, 1 month for accidental death and 24 months for suicide related deaths. 4. The main member’s minimum joining age is 18 and the maximum joining age is 74. 5. The waiting period for member above 74 years is 12 months. 6. Premiums on all policies must be honoured. Failure to do so lapses the policy without any notice. 7. Claims must be made within six months after death, however you must notify us of the death immediately. 8. No waiting period if you have an existing policy with an underwritten Funeral Undertaker.
I have read and agree to the Terms of Service
DECLARATION BY PROPOSER/PREMIUM PAYER
I declare to the best of my knowledge and belief that the particulars given above are true and correct. I understand and agree that any misrepresentation in this application will invalidate any benefit under this policy and that I undertake to abide by the terms and conditions of the Policy and with which I undertake to comply. The insurer shall not be liable for any amount until it has accepted first premium. I understand that I will not be covered for the months that I do not pay premiums, and that premiums are payable in advance. I further irrevocably authorize any doctor or other person who may be in possession of and/ or hereafter acquire any information concerning my health to disclose such information to the insurer and agree that this authority shall remain in force even after my death. I know and understand the contents of this declaration and I have no objection to consider it to be binding on my conscience.
Full Names and Surname
Date
Uploading Supporting Documents
ID Copy
Max. size: 512.0 MB
Other Copies
Max. size: 512.0 MB
