CareCard Basket Application Form

Transcription

1 CareCard Basket Application Form Please tick the Basket of your choice Star 27 Adult Basket 260 pm 4Star 24/7 Student Basket 1 StarBasket Jnr 140 pm Snr 145 pm 190 pm 4Star Additional Cover Spouse - 60 pm Junior 40 pm each Senior 45 pm each Please enter the number of additional covers you want One spouse and up to three students can be added to the 24/7 Adult Basket Up to two extra students can be added to the 2/7 Student Basket PINCIPAL MEMBE'S DETAILS Title First Names Surname Gender Male Female SA ID Number Birth Date Y Y Y Y M M D D Postal Address Town Tel Work Fax No TelHome Cell No Occupation Code SPOUSE AND STUDENTS DETAILS Spouse First Name Surname Gender Male Female SA ID Number Birth Date Y Y Y Y M M D D Junior or Senior Cover and Student's Full Names Birth Date 1 Junior Y Y Y Y M M D D 2 Junior Y Y Y Y M M D D 3 Junior Y Y Y Y M M D D I would like to be a CCA By ticking the CCAbox, I confirm that the details of the CareCard Business Model as well as the compensation plan have been fully explained to me. By signing here, I confirm that I have seen an official CareCard Membership Presentation and that the details of the cover contained in my selected Basket has been fully explained to me and I have read and I understand the terms and conditions as set out in the attached document and available at for the said cover. I have read and understand the official warning attached. Signature

2 CC No: Send the completed form to: INTODUCING CCA'S DETAILS Introducing CCA's Number Introducing CCA's Name Contact Number BIAN GHANSA PINCIPALS BENEFICIAY OF CHOICE NAME SA ID Number elationship: Contact No.: AUTHOISATION FO MONTHLY DEBIT ODE Enter the number of extras with the total monthly amount Monthly Basket Payment Extra Spouse 60 pm Extra Junior 40 pm Extra Senior 45 pm Total Monthly Debit Order Monthly debit orders will be processed on the last working day of each month I hereby authorise CareCard to issue payment instruction to my bank, in terms of this order to draw against the bank account below, for the collection of the amount indicated above. (The Total Monthly Debit Order), on a monthly basis, until further notice from myself with a 20 working day notice given in writing, this payment being in respect of the Basket of services selected above. I understand the payment date is the last working day of each month commencing on the start month as stated below. If there are two consecutive unmet payments, this contract and debit order instruction and mandate will be cancelled. I confirm that I have read the "Important Debit Order Information" in the attached document Bank Account Details Account Holders Name Bank Account Type Current Savings Transmission Branch Code Account Name Account No.: Signature of Account Holder Signature of Principal if different from the Account Holder Date of Signature Y Y Y Y M M D D Start Month CHAITY OF CHOICE Interim Charity of Choice eference Number

3 CareCard Membership Application On behalf of the CareCard Care4all Team, we would like to welcome you as a valuable Member. IMPOTANT INFOMATION FO YOU TO KEEP Your Name Your CC Number Your Introducing CareCard Advertiser s Information: Name Contact Number BIAN GHANSA CC Number address brianpghansar@gmail.com CONTACT DETAILS CAECAD HEAD OFFICE CareCard PMB (Pty) Ltd 2012/220399/07 CareCard Executive Director Operations: Jason Bingham Jason@carecard.co.za 218 Greyling Street, Pietermaritzburg, 3201 / PO Box 11939, Dorpspruit, 3206 Phone: / Fax: / admin@carecard.co.za / apps@carecard.co.za Websites: Public: / Members: 1STA BASKET FUNEAL & SELECT Underwritten by KGA Life (FSP 1580) KGA Client Service Select Call Centre SELECT ( ) 4STA BASKET 24/7 WOLD WIDE ACCIDENT COVE Underwriters Stalker Hutchison Admiral ((Pty) Limited (FSP No 2167) in accordance with the authority granted under Section 48A of the Short Term Insurance Act No. 53 of 198 on behalf of Santam Limited (FSP No 3416) Accident Notificatio / admin@carecard.co.za 4Star Basket Inform office@care4all.co.za PSG Insure (FSP No 7 Anita.Geldenhuys@psg.co.za Accident Expert ( / support@accidentexpert.co.za HIV/AIDS Notificati 0861 HIV CAE ( ) Mon to Fri 08:30 to 16:30

4 CareCard Company ules and egulations for CCA's IMPOTANT WANING 1 CareCard is committed to the highest ethical standard in its Business Plan and presentation of that Plan. 2 It is illegal for a Principal or CCA to persuade anyone to make a payment by promising benefits solely for getting others to join a scheme. 3 Do not be misled by claims that high earnings are easily achieved. 4 Success is more likely for people who learn communication and marketing skills through professional training, learning and reading as well as attending official CareCard training sessions, together with dedication, hard work and much effort.

5 CareCard Membership Application NOTES 1. Your CC No is your identification in CareCard. Please copy your CC No on this form s front page together with the details of your introducing CCA, for future reference. 2. This CCA must be the person who introduced you to CareCard. 3. Your beneficiary is the person who will receive any earnings and funeral/accidental death pay-outs, on your death. 4. It is vital that the banking details are filled in correctly. Please check them carefully. 5. If you are not the account holder, the authorised signature of the account holder must be in the first box and your signature in the second box. 6. Your charity of choice must have the minimum of 20 active nominations for it to start receiving funds from CareCard. If it does not have 20 active nominations, the interim charity chosen will receive your contribution in the interim. The interim charity must be an existing qualified charity. 7. By signing on the left of the application form, you confirm that you have seen an official CareCard presentation and the cover contained in your selected Basket has been fully explained to you and that you have read and understand the terms and conditions, as set out in this document and at for the said cover and services. You also confirm that you have read and understand the official warning attached. If you have ticked the CCA box, you confirm that the details of the CareCard Plan and the compensation model have been explained to you. 8. There is a one month admin waiting period. The 1Star Basket Select Products and the Star Basket cover and benefits start with your second payment. The 1Star Basket Funeral Cover has a three month waiting period from your second payment. 9. After completing the application form in full, please remove it from the cover and fax or it accompanied by the official Application Log Sheet provided by your introducing CCA. CareCard Important Debit Order Information I understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks and I also understand that the details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to me should enable me to identify the agreement. A payment reference is added to this form - CareCard - before the issuing of any payment instruction. I shall not be entitled to any refund of amounts which you have withdrawn while the authority was in force, if such amounts were legally owing to you MANDATE: I acknowledge that all payment instructions issued by me shall be treated by my above mentioned bank as the instructions had been issued by me personally. CANCELLATION: I agree that this authority and Mandate may be cancelled by me, such cancellation will not cancel this agreement. I will not be entitled to any refund of amounts which have been withdrawn while this authority was in force, if such amounts were legally owing by me. ASSIGNMENT: I agree that although this Authority and Mandate may be ceded to or assigned to a third party if the agreement is also ceded to or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. My signature as the account holder on the CareCard Member Application Form, confirms I have read and accept all the above.