Multisure

 
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:
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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 041-581 0746 or email it to admin@multisure.co.za
Main Member Details
Surname:  * Postal Address
Line1:
 *
First Names:  * Line2:
Known As:  *Compulsory City:  *
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:   Gender :

Payment Method
Cash
Debit Order
Internet Transfer
Credit Card
Choose Payment Method Above Employment Details


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Employer:
Employer Address:
Department:
Employee No:
Interested in Income Opportunity:
No Yes
Dependants
  Name Relationship ID No / Birth Date
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Member Verification
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Please note that a once-off R80,00 administration fee will be deducted with your first premium.