MultiSure

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. unless the two spouses/ partners fall into the same age category, eg both are in age group 14-59 or 60-74. 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 legal cover application form.

Click here to download our legal cover application form or continue with this online application if you are the main member applying for this policy.

IC Code:

00-00001

Recruiter Code:

* Please enter Recruiter's number (if any)

If the IC code above is 00-00001 then please inform us how you got to know about our company/ cover?

For example: "John Smit - friend" or "magazine advert with ref no..." etc

If you are the Main Member applying for this policy then you may proceed. If however you are loading this application on behalf of someone else then we will require the scanned application form to be attached to this application at the bottom of this page under Member Verification. Alternatively you may exit this page now and fax the completed application form to 086 623 1822 or email it to admin@multisure.co.za

Type: SA ID Number Other(YYMMDD)

Gender: Male Female

Internet Transfer

Credit Card

Employment Details

Interested in Income Opportunity: No Yes

DependantS

Child' includes your biological children and those legally adopted by you. Children can be covered under your policy if they are under 21 years old and still dependent on you or up to age 25 if they are still studying. If not then they must take out their own policy. New born children can be added to your policy at any time. You can select Extended Family Members (father, mother, brother, sister, in-laws, etc) to include in your policy further down below.

(if Birth Date then insert like this YYYYMMDD, eg if 24 Nov 1989 then insert 19891124)

Select Your Cover*

Member	Cover Amount	Monthly Premium	Tombstone R7000	Inkomo R7000	Grocery R3000	Air Time R500
o1 . Single with/without children in age group 14-59	R3000.00 R7000.00 R10000.00 R20000.00 R30000.00 R60000.00	R30 R45 R60 R100 R150 R240	R40	R40	R25	R5
o2 . Single with/without children in age group 60-75	R3000.00 R7000.00 R10000.00 R20000.00 R30000.00 R60000.00	R50 R90 R130 R215 R330 R640	R85	R85	R45	R8
o3 . Family cover where main member in age group 14-59	R3000.00 R7000.00 R10000.00 R20000.00 R30000.00 R60000.00	R35 R50 R70 R120 R175 R335	R45	R45	R30	R7
o4 . Family cover where main member in age group 60-74	R3000.00 R7000.00 R10000.00 R20000.00 R30000.00 R60000.00	R65 R130 R180 R300 R460 R900	R95	R95	R60	R10

Extended Family (Optional)

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.Please note that Extended Family must be added before you pay your first premium and cannot be added to your policy after that.

Optional Additional Extended Family up to Age 13

(Monthly Premiums Payable: R3000,00 = R15,00 ; R7000,00 = R25,00 ; R10000,00 = R35,00)

Optional Additional Extended Family Cover (Under 60 Age)

(Monthly Premiums Payable: R3000,00 = R25,00 ; R7000,00 = R40,00 ; R10000,00 = R50,00)

Optional Additional Extended Family Cover (From 60 to 74)

(Monthly Premiums Payable: R3000,00 = R45,00 ; R7000,00 = R85,00 ; R10000,00 = R120,00)

Answer Medical Questions?

No Yes

Total Monthly Premium:

(The IP address of this computer is being recorded. Please answer below statement truthfully to prevent repudiation of any future claims.)

I am the main member applying for this policy:

Yes

Please note that a once-off R130,00 administration fee will be deducted with your first premium.

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