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

OUR PRODUCTS

Type: SA ID Number    Other(YYMMDD)
Gender: Male Female

Payment Method

Cash
Debit Order
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)

01.

02.

03.

04.

05.

06.

07.

08.

09.

10.

Select Your Cover*

Member Cover Amount Monthly Premium Select Cover Tombstone R7000 Inkomo R7000 Grocery R3000 Air Time R500 Total Premium
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

Member Verification

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 2 years?
Yes No
Have you or any of your dependents been hospitalised for any illness during the past 2 years?
Yes No

If you answered Yes to any of the questions above, please provide us with full details.

Total Monthly Premium:

Member Verification

(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 No
Please note that a once-off R130,00 administration fee will be deducted with your first premium.
Terms and Conditions