FUNERAL COVER APPLICATION FORM

Transcription

1 Universal Cover (Pty) Ltd Universal House, 15 Tambach oad, Sunninghill Park, Sandton, 2191 PO Box 1411, ivonia 2128 Tel: Fax: Universal Cover (Pty) Ltd is a Licensed Financial Services Provider FSP Underwritten by Safrican Insurance Company Limited An Authorised Financial Services Provider, FSP no.: Head Office Safrican First floor, Grosvenor Corner, 195 Jan Smuts Avenue, osebank PO Box 616, Johannesburg Telephone: Facsimile: Company eg No.: 1935/007463/06 FUNEAL COVE APPLICATION FOM FO OFFICE USE ONLY Policy number: Type: Funeral Cover Funeral Cover Plus Universal staff A. POLICYHOLDE DETAILS Title: Full names: Surname: Identity number: Date of birth: Passport number: Nationality: esidential address: Postal code: Postal address: Province (please select): Contact details: Daytime number: Postal code: Gauteng Eastern Cape KwaZulu-Natal Free State Western Cape Mpumalanga North-West Northern Cape Limpopo Cell number: B. SPOUSE S DETAILS Full names Surname Identity number Date of birth C. CHILDEN S DETAILS Full names Surname Identity number/ Date of birth elationship

2 D. EXTENDED FAMILY S DETAILS Full names Surname Identity number/ Date of birth elationship Benefit amount Premium amount E. BENEFICIAY (The beneficiary will be paid the benefit in the event of the death of a principal member) Name Surname Identity number elationship F. SINGLE BENEFIT CHOICES Benefit A Benefit B Benefit C Benefit D Benefit E Insured person Principal member (18 64 years old) Premium G. FAMILY BENEFIT CHOICES Insured person Benefit A Benefit B Benefit C Benefit D Benefit E Principal member (18 64 years old) Spouse Children years old Children 6 13 years old* Children 1 5 years old* Children 0 11 months old* Stillborn* Premium *Please see the attached Summary Terms and Conditions for benefit limits for children. H. EXTENDED FAMILY COVE BENEFIT CHOICES Age of extended family member at entry date Benefit A Benefit B Benefit C Benefit D Below the age of 65 years ** years old years old Premium ** Please see the attached Summary Terms and Conditions for benefit limits for children. I. SENIO MEMBE BENEFIT CHOICES Age of extended family member at entry date Benefit A Benefit B Benefit C Benefit D ate per principal member per month (65 74 years) ate per principal member per month (75 84 years) ate per principal member per month (85 94 years) Premium

3 J. ADDITIONAL OPTIONAL BENEFITS Additional optional benefits Age of principal member should be between years at entry Principal member only Principal member and eligable spouse Per additional child date Grocery benefit Not applicable Not applicable Memorial benefit Not applicable Beef benefit (Inkomo benefit) No. of children Premium Additional accidental death benefit Age of principal member should be Benefit A Benefit B Benefit C Benefit D Benefit E between years at entry date Single Family Premium K. TOTAL AMOUNT PAYABLE CALCULATION SUMMAY Description Single member (section F) Family (section G) Extended family (section H) Senior member (Section I) Additional optional benefits (Section J) Additional accidental death benefit (Section J) TOTAL AMOUNT DUE ***Including risk premium, commissions and fees due Total amount payable*** L. PAYMENT DETAILS PAYOLL DEDUCTION: I hereby authorise the Employer to deduct from my salary each month the total amount due for the cover I have chosen and to pay this amount to Safrican Insurance Company Limited ( Safrican ) or Universal Cover (Pty) Ltd or their duly appointed representatives. In the event of this deduction not being successful, the policy will end, subject to the grace period as described in the Terms and Conditions. No cash payments are accepted for arrear or any other premiums. I understand that this signed application form must be received by Universal Cover (Pty) Ltd within 12 working days prior to the deduction date; if not, the premium will only be deducted and cover will only start in the following calendar month. PINCIPAL MEMBE S SIGNATUE AND/O DEBIT ODE AUTHOITY: Name of bank: Branch code: Account type: Cheque Savings Transmission Name of accountholder: Account number: I hereby authorise Safrican Insurance Company Limited ( Safrican ) or Universal Cover (Pty) Ltd or their duly appointed representatives to start a debit order withdrawal from my account on the (day) of (month) (year) and on the day of each month thereafter, with a possible percentage increase each year, for the total amount due for the cover I have chosen. I understand that the debit order will be run on the date I have chosen; if for whatever reason it is not successful, the policy will end, subject to the grace period as described in the Terms and Conditions. No cash payments are accepted for arrear or any other premiums. I understand that this signed application form must be received by Universal Cover (Pty) Ltd within 12 working days prior to the chosen deduction date; if not, the total amount due will only be deducted and cover will only start in the following calendar month. POLICY PAYE S SIGNATUE

4 M. DECLAATION I declare to the best of my knowledge and belief that the information given above is true and correct. I understand and agree that any willful misrepresentation in this application form will invalidate any benefit under this Policy. I declare that I have read and understood the terms and conditions attached to this Policy, and understand their meaning and effect, and undertake to abide and to be bound by the terms and conditions of the Policy. Universal Cover (Pty) Ltd or Safrican Insurance Company Limited ( Safrican ) or their duly appointed representatives shall not be liable for any amount until it has accepted this application and this Policy is in force. If any person is over the age limit when joining, the claim will be repudiated and risk premiums refunded. I understand that this product is offered to me on a non-advice basis, and that should I need to, I may contact Universal Cover or Safrican's offices for advice and assistance. PINCIPAL MEMBE S SIGNATUE Please the completed application form to cover@universal.co.za or fax to N. INTEMEDIAY DETAILS (if applicable) Name of brokerage: FSP number: Tel number: Brokerage code: Fax number: BC code: I declare that I have checked the details provided in this document, and to the best of my knowledge the information provided is correct and complete. INTEMEDIAY S SIGNATUE O. CONTACT DETAILS YOU POLICY IS UNDEWITTEN BY: Safrican Insurance Company Limited ( Safrican ) eg. No. 1935/007463/06 An authorised Financial Services Provider FSP No Safrican is authorised to sell the following products: Long-term Insurance: Category A, B Safrican holds professional indemnity and fidelity insurance cover. SHOULD YOU EQUIE ASSISTANCE KINDLY CONTACT: Safrican Head Office First Floor, 195 Jan Smuts Avenue, osebank, 2000 PO Box 616, Johannesburg, 2000 Tel: Fax: (011) Claims Fax: Query Line Fax: (011) IF YOU HAVE ANY EASON TO COMPLAIN, KINDLY CONTACT: Compliance Officer Fax: (011) or compliance@safrican.co.za Should a complaint not be resolved to your satisfaction, you may escalate the complaint to either the FAIS Ombudsman or the Long-term Insurance Ombudsman whose details are set out below. Note that you must be able to show that you have already attempted to resolve the matter with Safrican first. FAIS Ombudsman Financial Services Board P.O. Box 74571, Lynnwood idge, 0040 Tel: (012) Fax: (012) The Ombudsman of Long-term Insurance Private Bag x45, Claremont, 7735 Tel: (021) Fax: (021)

5 P. TEMS AND CONDITIONS FUNEAL BENEFITS: The funeral plan provides for a cash payment of a death claim of a Principal Member, his/her Spouse, Children, Extended Family Members and Wider Children, where applicable. FUNEAL PACKAGE: The funeral package consists of the following benefits: Single benefit Family benefit Optional extended family benefit Senior member benefit Additional optional benefits, as specified. INSUED PESONS DEFINITIONS: Principal Member: Any individual, who is a member of Universal Cover (Pty) Ltd Funeral Cover Scheme, from age 18 years, who is allowed to participate in the policy, in terms of the eligibility conditions as stated in the Policy Document. The maximum entry age for a Principal Member is 94 years. A Principal Member must live in South Africa. Spouse: A person married to the Principal Member by law or tribal custom or under the tenets of any Asian religion, which shall include a Common Law Spouse of the Principal Member. The maximum entry age for a Spouse is 65 years. Only a maximum of two Spouses may be covered per policy. Common Law Spouse: A person who is deemed by Safrican, at its sole discretion, to be a Spouse, considering the circumstances of each case, and shall include, where applicable, customary marriages, or a relationship between two people of the same gender, or a relationship between two people who have lived together for at least six consecutive months prior to the date of death of the Spouse. Child: An unmarried child of the Principal Member, younger than age 21 years, including a stepchild, posthumous child, an illegitimate child, a legally adopted child or a stillborn child (must be stillborn from the 26th week of pregnancy). Only 2 stillbirth claims will be accepted per family during the term of the Policy. Cover for Children is extended to under age 26 years if the Child is a full-time student at a recognised educational institution. This does not include part-time and correspondence students. Children who are mentally disabled or totally and permanently disabled before age 21 years, who are unable to care for themselves, are covered until cover for the Principal Member ends. Details of any children of a Common Law Spouse, illegitimate child and stepchild must be supplied to Safrican at the time that the Principal Member joins the scheme, or within 1 month of the child becoming eligible for cover. Failing this, Safrican will require satisfactory proof to support any claim. Optional Extended Family: Family members, who are dependent on the Principal Member for financial assistance in the event of their death, may be covered. These include parents, parents-in-law, uncles, aunts, brothers, sisters, nephews, nieces, grandparents and children (who are age 22 years and older) of the Principal Member. Please Note: Up to 10 Extended Family members may be covered. Only in case of a marriage may Extended Family (parent-in-law) be added, provided the maximum number of Extended Family Members has not been exceeded (approval to be granted by Safrican before premiums are amended). Extended Family members may be covered multiple times under the Plan, provided such Extended Family members are not nominated more than once by the same Principal Member and the maximum benefit limit of is not exceeded for such Extended Family members across all Safrican plans. Dependants: means a Spouse, Children, Extended Family and Wider Child, where applicable. TEMS & CONDITIONS: Each Principal Member must complete an application form choosing his/her Spouse, Children, Extended Family Members and Wider Children, where applicable. Benefits end on the date of death of the Principal Member, non-payment of premiums (subject to the Grace Period), or withdrawal from the Plan by the Principal Member, which ever event may occur first. Premiums are paid up to death of principle member. Premium rates will be reviewed regularly. A thirty day notice period will apply. All children may be covered multiple times under the Plan, provided that: The benefit for children younger than 6 years cannot be greater than the maximum benefit limit of across all Safrican plans. The benefit for children younger than 14 and older than 6 years cannot be greater than the maximum benefit limit of across all Safrican plans. Should a Principal Member have underpaid his/her premium, the benefit payable in respect of a claim will be reduced in proportion to the underpayment. If any person is over the age limit when joining, the claim will be repudiated and risks premiums refunded. The policyholder is entitled to be provided, upon request, with a copy of the Policy Document. CONTINUATION OPTION: There is an option for Principal Members to continue their and their dependants cover, where applicable, on an individual policy of funeral insurance, after their cover ceasing on this Scheme. Where the Principal Member dies or for whatever reason withdraws from this Scheme, there is an option for any of the Principal Member s dependants under this Scheme to continue their and the other dependants cover, where applicable, on an individual policy of funeral insurance, after their cover ceasing on this Scheme. Both above options must be exercised in writing and within 1 (one) calendar month of the date the originating policy was cancelled. A separate policy of insurance will be issued in respect of this continued cover. This separate policy shall have its own terms and conditions. DUPLICATE COVE: A Principal Member, his/her Spouse and Children may be covered under any number of Compulsory Group Funeral Schemes. A Principal Member, his/her Spouse and/or Children may be covered once in a Voluntary Group funeral scheme as a Principal Member and only once or more than once as a dependent in any Voluntary Group Funeral Scheme underwritten by Safrican, provided that the total amount of cover does not exceed per insured person. GACE PEIOD: A one-month grace period is allowed to pay any premium once the policy is in force. If the premium is not paid within that month, the cover will end without further notice. WAITING PEIODS: A waiting period is the initial period of an insurance policy during which the insured person is not provided with cover, but the insurance premium remains payable. For insured persons on registered medical schemes administered by Universal Healthcare Administrators, Universal 360 loyalty programme members or employees on the Universal Occupational Health Plan: Younger than 65 years - zero months waiting period applies from the start date of cover for claims due to natural causes years 6 months waiting period applies from the start date of cover for claims due to natural causes. 75 years and older - 12 months waiting period applies from the start date of cover for claims due to natural causes. For all other insured persons: Younger than 75 years - six months waiting period applies for claims due to natural causes. 75 years and older - 12 months waiting period applies for claims due to natural causes. The principal member opting for a higher benefit for any person insured under the policy (from the start date of the increased cover only to the amount by which the benefit increased) the following waiting periods apply: Younger than 75 years - six months waiting period. 75 years and older - 12 months waiting period. For cover for senior members who take funeral cover from the age of: years - a waiting period of six months applies years - a waiting period of 12 months applies. For cover for extended family from the age of: 0-74 years - a waiting period of six months applies years - a waiting period of 12 months applies. Accidental death claims: Only accidental death claims will be paid immediately, provided the policy for the principal member and/or dependents (where applicable) is in force. Outstanding premiums during waiting period: Where any premium payment is missed and thereafter paid, the part of the waiting period not completed at the point when the premium was not paid, will apply from the date the premium is paid. Where a policy is reinstated, a new waiting period will commence from the resumed date of cover. EXCLUSIONS: No benefit will be paid if death is directly or indirectly caused by or attributable to: Terrorism or war (whether declared or not). adioactive contamination, whether directly or indirectly. Suicide will not be covered during the first two years of membership for any insured person. Divorced spouses at the start of the policy are not covered as Spouses, and cover for divorced spouses as Spouses who divorce during the term of the policy will end immediately on divorce. Divorced spouses may be covered as Extended Family, on Schemes or Policies which offer Extended Family cover. COOLING OFF PEIOD: The Principal Member has a 30 day cooling off period from receipt of this document to examine the policy. Provided that no death or claim has taken place in this period, he/she must inform Universal Cover (Pty) Ltd in writing if he/she chooses not to take up the policy. All premiums already paid will be refunded, less the cost of any risk cover and administration fee. SUENDE VALUES / CESSION / LOANS: This policy has no surrender value, and may not be ceded or pledged in any way. No loans will be granted against this policy. FAUDULENT CLAIMS: Safrican Insurance Company Limited ( Safrican ) or Universal Cover (Pty) Ltd or their duly appointed representatives will not pay any fraudulent claim that is made against this policy. Safrican Insurance Company Limited ( Safrican ) or Universal Cover (Pty) Ltd or their duly appointed representatives will, at its own discretion, be entitled to cancel this policy, and any other policy held by the Principal Member or claimant, with immediate effect, should any fraudulent claim be made with the knowledge or intent of the Principal Member or claimant to Safrican Insurance Company Limited ( Safrican ) or Universal Cover (Pty) Ltd or their duly appointed representatives detriment. ADDITIONAL OPTIONAL BENEFITS: Memorial Benefit: The Benefit specified in the Schedule shall be due for payment on the first anniversary date of the death, where there has been a valid claim of a Principal Member and/or Spouse. The Memorial Benefit payee must contact Safrican with a request for payment of the Benefit within three months following the anniversary of the date of death of the deceased Principal Member or Spouse, failing which the benefit will be forfeited. This benefit is available at an additional cost. Age of principle member should be between years at entry date. Grocery Benefit: In the event of the death of a Principal Member, the Grocery Benefit of will be paid over a period of one year in instalments per month. This benefit is available at an additional cost. Age of principle member should be between years at entry date. Beef Benefit (Inkomo benefit): The Beef Benefit has been structured specifically to provide livestock required for the traditional funeral ceremony and following celebrations, or cash in the event of the death of any Principal Member, Spouse and Children (where applicable). This benefit is available at an additional cost. Age of principle member should be between years at entry date. Additional Accidental Death Benefit: In the event of the death of a Principal member and/or dependants, the selected Accidental Death Benefit will be paid in addition to the funeral benefit. An accident is defined as being any specific event, occurring at an identifiable time and place that is unplanned and unexpected by the person insured, resulting from unforeseen and unintentional circumstances, from an external source to the body. This benefit is available at an additional cost. Age of principle member should be between years at entry date. SUMMAY CLAIMS POCEDUE: In the event of a death, a Claim Notification Form must be requested from a Safrican office, and submitted together with the relevant supporting documents within 90 (ninety) days of the date of death. Failure to do so within 90 (ninety) days from the date of death will result in the benefit being forfeited. Documents to be submitted include, but are not limited to: Fully completed Claim Notification Form. Proof of Death: (BI-5) Original computer produced or faxed certified Death Certificate; or (BI-18) Original or faxed certified copy of unabridged Death Certificate; or (Bl-20) Original or faxed certified copy of Abridged Death Certificate in respect of stillborn, together with supporting medical documents. (BI-1663) A copy of the Notification of death Certified copy of Principal Member s Identity Document Certified copy of deceased s Identity Document Certified copy of claimant s Identity Document Current bank statement of the claimant See the Claim Notification Form for further required documents. Safrican Insurance Company Limited ( Safrican ) or Universal Cover (Pty) Ltd or their duly appointed representatives reserves the right to request further documentation or information as it may deem necessary to accurately assess a claim. Safrican Insurance Company Limited ( Safrican ) or Universal Cover (Pty) Ltd or their duly appointed representatives will endeavour to settle the claim within 48 working hours, provided all the claim procedure criteria have been met. Faxed copies must be clearly certified by the Police or a Commissioner of Oaths. The relevant details of the Police or Commissioner of Oaths must be clear. Documentation submitted other than those listed, will not be accepted. Affidavits are not accepted INTEMEDIAY SEVICES: Universal Cover will levy administration costs, service fees and commissions up to maximum of 50% of the total monthly amount payable by policy holders.