Form

Welcome to Somnotho Funeral Services

Applicant 1/3

Gender

Tittle

Spouses Details 2/3

Gender

Tittle

PARTICULARS OF INSURANCE BEING APPLIED FOR 3/3

Select your plan

PLAN A (R90 pm) - Family age 18-65 get standard service plus R2500

PLAN B (R140 pm) - Family age 65-74 get standard service plus R3500

PLAN C (R170 pm) - Family age 75-86 get standard service plus R3500

PENSIONERS (R180 pm) - Basic Funeral

I confirm that the above particulars are correct.

Confirm

DEPENDANTS INCLUDING SPOUSE

Dependant 1

Dependant 2

Dependant 3

Dependant 4

Dependant 5

Dependant 6

Dependant 7

Dependant 8

Dependant 9

Dependant 10

Dependant 11

Dependant 12

Dependant 13

Dependant 14

Dependant 15

NEED AND AFFORDABILITY ANALYSIS

Client’s Declaration

I declare that the above information is a true and correct reflection of my income and expenditure and that the product is suitable to address my needs. I further declare that the information given to me in connection with the

Confirm

A. Net income

B. Total Expenses

A-B = Available Income

product is sufficient to assist me in making an informed decision about the product. I declare that the premium in respect of this policy is affordable to me. Failure to continue with premium payment will result in the loss of valua- ble SCHEM and all premiums paid will be forfeited.

CLIENT’S ADVICE RECORD

Product (s) Recommended Suite YES NO

I confirm that the provisions in the application form eg replacement provision and option to increase premium with R10 were explained to me before I signed the application form.

I confirm

I confirm that the recommended product, terms and conditions, waiting periods of 6 months were explained to me.

I confirm

I acknowledge and accept monthly premium below to be deducted via debit/cash by SOMNOTHO. I further declare that I understand that failure on my part to continue with premium payment will result in the laps of the policy as well as the loss of SCHEM.