New Member Registration

Please note that if you are married or in a permanent relationship then the older one of you and your spouse / partner must be the main member and that person's details must appear below next to Surname, First Names, etc. This is not the case with our legal cover product where any one of the parties can be the main member. Click here if you want to view our LEGALSURE application form

IC Code: 00-10816 Recruiter Code:
Please enter Recruiter's number (if any)
Surname:  * Postal Address
Line1:
First Names:  * Line2:
Known As:  *Compulsory City:
Type: SA ID Number    Other (YYMMDD)
ID Number:  *No Spaces Post Code:
Phone (Day): Residential Address
Line1 : 		=]
Phone (Night): Line2 :
Mobile:  *No Spaces City :
Fax: Province :
eMail: Post Code:
    Gender :
Beneficiary Id:    
Beneficiary:    
Payment Method:
None
Cash
Debit Order
Internet Transfer
Credit Card
Bank Details Employment Details
Account Holder:
Employer:
Bank:
Employer Address:
Branch:

Branch Code:

Account Type:
Department:
Account No:
Employee No:

Date of deduction:
0 1 5 15 20 25 26 28 Last Day

Interested in Income Opportunity:
None No Yes

Month in which to Start Deduction:
None 1 2 3 4 5 6 7 8 9 10 11 12

 

Dependants
  Name Relationship ID No / Birth Date
1
2
3
4
5
6
Select Your Cover
Funeral Cover
  Member Cover Amount Monthly Premium  
1. Single with/without children
in age group 14-59
R3000.00 R30
R10000.00 R55
R20000.00 R95
2. Single without children
in age group 60-74
R3000 R50
R10000.00 R125
R20000.00 R210
3. Family cover where main member
in age group 14-59
R3000 R35
R10000.00 R60
R20000.00 R110
4. Family cover where main member
in age group 60-74
R3000 R65
R10000.00 R175
R20000.00 R295
Below you have the option to take out cover for any other family members including your parents, parents-in-law, brothers, sisters, aunts, uncles, etc.
Optional Additional Extended Family up to Age 13
(Monthly Premiums Payable: R3000,00 = R15,00 ; R7000,00 = R25,00 ; R10000,00 = R35,00)
Name Relationship ID No. Cover Amount
Optional Additional Extended Family Cover (Under 60 Age)
(Monthly Premiums Payable: R3000,00 = R25,00 ; R7000,00 = R40,00 ; R10000,00 = R50,00)
Name Relationship ID No. Cover Amount
Optional Additional Extended Family Cover (From 60 to 74)
(Monthly Premiums Payable: R3000,00 = R45,00 ; R7000,00 = R85,00 ; R10000,00 = R120,00)
Name Relationship ID No. Cover Amount
Total Monthly Premia
Additional Information (Required)
Have you or any of the dependants/extended family above suffered from any of the following in the past?
Tuberculosis/HIV AIDS/PNEUMONIA Yes No
Heart Yes No
Cancer Yes No
Kidney failure Yes No
Have you or any of your dependents been bedridden for a period of more than 3 months? Yes No
Have you or any of your dependents received treatment from a doctor or clinic for the same illness on more than one occasion during the past year? Yes No
Have you or any of your dependents been hospitalised for any illness during the past year? Yes No
If you answered Yes to any of the questions above, please provide us with full details.
 		   
Please note that a once-off R80,00 administration fee will be deducted with your first premium.

Please note that the ip address of this computer is being captured. If you are not the person taking out the policy or the bank account holder whose name appears above then a signed application form needs to be posted or faxed to us by the person applying for this cover to prevent repudiation of claims in future. Please post the signed application form to MultiSure (Pty) Ltd, PO Box 63943, Greenacres, Port Elizabeth 6057 or fax to 041-363 1479.