LATEST NEWS

1
Please note that all our offices will be closed on Monday, 30 April 2018.

2
Our training videos are available to view at www.vimeo.com/multisure

3
Our new George office is now open.

4
Our new and free APP to manage your MS Business is available for download in Playstore.

5
All monthly Top Performers now receive a FREE gift from us sent to them at month-end!

6
We are in the process of opening more offices in major cities.
MultiSure Corporation Pty Ltd
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  •   081 428 4828

FUNERAL COVER

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 the 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 Funeral 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

PERSONAL INFORMATION

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 completed and signed (by the main member) scanned application form to be attached to this online application during Step 7 of the process. Alternatively you may download the Funeral cover application form here, exit this page now and fax the completed and signed (by the main member) application form to  086 623 1822 or email it to admin@multisure.co.za


Type: SA ID Number    Other(YYMMDD)



Gender: Male Female

PAYMENT METHOD

Cash
Debit Order
Internet Transfer
Credit Card
Our bank details- Bank: ABSA, Acc name: MultiSure (Pty) Ltd, Acc number: 4052301886 Branch: 632005 Reference: Use your initials and surname or identity number. Please fax your proof of payment to 086 623 1822 or email to admin@multisure.co.za Your application will be processed after we receive proof of your first payment which is your premium amount reflected at the bottom of this page after selecting same plus a once-off admin fee of R150. If you select the Debit Order or Credit Card option as payment method we will process your application within 12 working hours.
Please note that if you choose the Cash or Internet Transfer payment option, and we do not receive proof of payment within 48 working hours then your application will be deleted from our system meaning you will have to reapply for the cover.

Employment Details

Interested in Income Opportunity: No Yes
If you are making use of our business opportunity then you can select a username to use as part of your profile with us. Please type one to check if it is available or leave blank for now. Please note that a R75 monthly business fee will be payable after we have received your first premium and administration fee.

DEPENDENTS

“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 during Step 6.

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

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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

R280

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

o5 . Single with/without children in age group 75-85 group

R10000.00

R20000.00

R30000.00

R60000.00

R145

R240

R350

R680

R105

R105

R55

R13

o6 . Single with/without children in age group 86-90

R7000.00

R10000.00

R20000.00

R30000.00

R60000.00

R130

R160

R290

R430

R840

R125

R125

R65

R15

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; R20000,00 = R60,00)

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06.

Optional Additional Extended Family Cover (Under 60 Age)

(Monthly Premiums Payable: R3000,00 = R25,00 ; R7000,00 = R40,00 ; R10000,00 = R50,00 ; ; R20000,00 = R90,00)

01.

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Optional Additional Extended Family Cover (From 60 to 74)

(Monthly Premiums Payable: R3000,00 = R45,00 ; R7000,00 = R85,00 ; R10000,00 = R120,00 ; R20000,00 = R205,00)

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Total Monthly Premium:

FINAL STEP

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.

Verification

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

I am the main member applying for this policy:
Yes No
Verification Document :

If you are loading this application on behalf of someone else then we will need proof that the applicant took out the policy with us by attaching a copy of the signed application form to this application and sending it to us or a recording of the person agreeing to the policy and the terms and conditions.

Alternatively, you may download the funeral cover application form here, exit this page now and fax the completed and signed (by the main member) application form to 086 623 1822 or email it to admin@multisure.co.za

Please note that a once-off R150,00 administration fee will be deducted with your first premium.
Terms and Conditions
 
Check your details before submitting the form








Check Details

FUNERAL COVER

Recruiter Code:   Source Info:  

PERSONAL INFORMATION

Surname:  
Postal Address (Line 1):  
First Name:  
Line 2:  
Known AS (Optioiinal):  
Type:  
City:  
ID Number:  
Province:  
Phone (Day):  
Post Code:  
Phone (Night):  
Residential Address (Line 1):  
Mobile:  
Line 2:  
Fax:  
City:  
email:  
Province:  
Confirm eMail:  
Post Code:  
Beneficiary:  
Beneficiary Id:  

PAYMENT METHOD


EMPLOYMENT DETAILS

Employer:  
Employer Address:  
Department:  
Employee No:  

DEPENDENTS

Name:   Relationship:   ID No / Birth Date  
Name:   Relationship:   ID No / Birth Date  
Name:   Relationship:   ID No / Birth Date  
Name:   Relationship:   ID No / Birth Date  
Name:   Relationship:   ID No / Birth Date  
Name:   Relationship:   ID No / Birth Date  
Name:   Relationship:   ID No / Birth Date  
Name:   Relationship:   ID No / Birth Date  
Name:   Relationship:   ID No / Birth Date  
Name:   Relationship:   ID No / Birth Date  

EXTENDED FAMILY (OPTIOINAL)

- Optional Additional Extended Family up to Age 13


Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  

- Optional Additional Extended Family Cover (Under 60 Age)


Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  

- Optional Additional Extended Family Cover (From 60 to 74)


Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  
Name:   Relationship:   ID No / Birth Date   Cover Amount:  

Answer Medical Questions

Answer:  
Tuberculosis/HIV AIDS/PNEUMONIA:  
Heart:  
Cancer:  
Kidney failure:  
Have you or any of your dependents been bedridden for a period of more than 3 months?  
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?  
Have you or any of your dependents been hospitalised for any illness during the past 2 years?  
Details:

VERIFICATION

VERIFICATION:  

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