Application Form | Asibonge Funerals

A. Policyholder / Main Member Details (The Payer)

Title

Mr Mrs Ms Dr

Gender

Male Female

First Names

Surname

South African ID Number / Passport

Date of Birth (DD/MM/YYYY)

Marital Status

Cell Phone Number

Alternative Number

Email Address

Residential Address

Postal Code

B. Policy Replacement (For Immediate Cover)

Transferring from another active policy?

YES NO

Previous Insurer / Parlor Name

Previous Policy Number

Cancellation Date

C. Package & Policy Selection

Selected Plan Name

Total Monthly Premium (R)

D. Immediate and Extended Family Members

* Note: If you don't have information of dependants right now, you can leave this part blank and finish it later with our agent.

Dependant Type	Full Names & Surname	ID Number / Birth Cert	Age

F. Beneficiary Nominations

Full Names & Surname

ID Number

Relationship

Contact Number

G. Premium Payment Authority (Debit Order)

Payment Method

Bank Debit Order Cash / EFT

Account Holder Name

Bank Name

Branch Name & Code

Account Number

Account Type

Cheque Savings Transmission

Preferred Deduction Date

H. WAITING PERIODS & LEGAL DECLARATIONS

1. General Waiting Period: I acknowledge and understand that there is a standard 3-month waiting period for death by natural causes.

2. Tombstone Benefit Waiting Period: I acknowledge and understand that there is a 6-month waiting period for the tombstone benefit.

3. Immediate Cover for Transfers: If I am transferring from another active funeral policy (and have provided valid proof), I understand that Asibonge Funerals will cover me immediately (waiving the standard waiting period).

4. POPIA Consent: I hereby give consent to the processing, collection, and storing of my personal information and that of my dependents by Asibonge Funerals (Pty)Ltd, strictly for the purpose of policy administration and processing claims as required by the Protection of Personal Information Act.

5. Duty of Disclosure: I warrant that all information provided in this form is true, correct, and complete. I understand that non-disclosure or misrepresentation of facts may render the policy void and result in the repudiation of claims.