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 funeral cover application form or continue with this online application if you are the main member applying for this policy.
IC Code: 00-38920 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

Main Member Details


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:
Confirm eMail:  l Gender :
 *Who must receive claim amount in case of the Main Member's death?
Beneficiary: *    
Beneficiary Id: *    
If the Beneficiary inserted here is also your Spouse or Partner and you want that person covered in your funeral policy then you must again insert the same person's details under "Dependants" below please.
Payment Method *
Cash
Debit Order
Internet Transfer
Credit Card
SASSA
SASSA Debit Order
Bank Details Employment Details
Account Holder:
*
Employer:
Bank:
*
Employer Address:
Branch:

Branch Code:

Account Type:
*
Department:
Account No:
*
Employee No:

Day first payment will be made: *

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.

  Name Relationship ID No / Birth Date
(if Birth Date then insert like this YYYYMMDD, eg if 24 Nov 1989 then insert 19891124)
1
2
3
4
5
6

Select Your Cover *

  Member Cover Amount Monthly Premium Select Cover
     
1. Single with/without children
in age group 14-59
R3000.00             R30
R7000.00             R45
R10000.00             R55
R20000.00             R95
     
2. Single without children
in age group 60-74
R3000.00             R50
R7000.00             R90
R10000.00             R125
R20000.00             R210
     
3. Family cover where main member
in age group 14-59
R3000.00             R35
R7000.00
            R50
R10000.00             R60
R20000.00             R110
     
4. Family cover where main member
in age group 60-74
R3000.00             R65
R7000.00
            R130
R10000.00             R175
R20000.00             R295
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)
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

Additional Information Required


Have you or any of the dependants/extended family above suffered from any of the following in the past? Answer Answer
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 R120,00 administration fee will be deducted with your first premium.

SEND US YOUR DETAILS IF YOU DO NOT WANT TO COMPLETE THE FORM ON THIS PAGE.
WE WILL CALL AND ASSIST YOU WITH TAKING OUT A POLICY WITH US.