LEGAL COVER

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

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 5 of the process. Alternatively you may 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

Gender:

PAYMENT METHOD

Cash

Debit Order

Internet Transfer

Credit Card

Employment Details

Interested in Income Opportunity: Yes No

Please note that a R75 monthly business fee will be payable after we have received your first premium and administration fee.

DEPENDENTS

Here you can fill in the names of your spouse/partner and/or children under the age of 21 who are still dependent on you and whom you wish to have covered under the same membership at no additional cost.

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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.

Check your details before submitting the form