form - Mdalisu Funeral Administrators
APPLICATION FORM Policy No: MFA01___
I the undersigned hereby apply for membership and benefits, as indicated by Mdalisu Funeral Administrators.
New Policy or Alteration on your existing policy
Policy plan: Funeral
Burial:
PLAN
A
B
C
Extra benefit
1. PERSONAL DETAILS OF MAIN MEMBER
Title
Full names
ID No
Physical Address
Cell No
Surname
Marital Status
Postal Address
Tel No (H)
Work Name
Date of Birth
Tel No (O)
Job/Occupation
E-Mail
2. PERSONAL DETAILS OF SPOUSE
Title
ID No
Address
Full names
Surname
Date of Birth
Contact no:
3. DEPENDANT CHILDREN
Initials and Surname
1
2
3
4
5
6
7
8
Sex
Identity number or Date of Birth
Premium
Sex
Identity number or Date of Birth
Premium
4. EXTENDED MEMBERS
Initials and Surname
1
2
5. BENEFICIARY/IES
1
Current Main Member’s Age ______
6. DEBIT ORDER
PLANOPTIONTotal Premium R______
Account Holder: ___________________________ Bank __________________ Branch: ________________________
Branch Code: ________________ Account No: ________________________________ Account Type
Deduction Date: __________
This signed Authority and Mandate refers to our contract as dated as on signature hereof ("the Agreement"). I / We hereby authorize you to issue and deliver payment instructions to the
bank for collection against my / our abovementioned account at my / our above mentioned bank (or any other bank or branch to which I / We may transfer my / our account) on condition
that the sum of such payment instructions will never exceed my / our obligations as agreed to in the Agreement, and commencing on the commencement date and continuing until this
Authority and Mandate is terminated by me / us by giving you notice in writing of no less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address
indicated above.
i. On the _______ day ("payment day") of each and every month commencing on _____________. In the event that the payment day falls on a Saturday, Sunday or recognized South
African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you
are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account Monthly; on or after the dates when the obligation in
terms of the Agreement is due and the amount of each individual payment instruction may not be more or less that the obligation due.
MANDATE
I / We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally.
CANCELLATION
I / We agree that although this Authority and Mandate may be cancelled by me / we, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund of amounts
which you have withdrawn while this authority was in force, if such amounts were legally owing to you.
ASSIGNMENT
I / We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded 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.
Signed at _________________ on this _________________ day of _________________ 20___
Signature of Account Holder: ________________________
7. DECLARATION
Date:____/____/______
I the undersigned hereby declare and warrant all information supplied herein, to be true and complete. I am aware, of any non-disclosure or misrepresentation of information which is
material to the determination of the risk, may lead to the policy being declared null and void, in which case all premiums paid, will be forfeited. I am certain that the product which I am
applying for meets my needs and feel that I have all the necessary information in order to make an informed decision in respect of the purchase thereof. I have been advised on the product
features, premiums and all its terms and conditions. I was given a flyer which includes product features, premiums and all product terms and conditions. I also confirm that I have read and
understood all the terms and conditions.
Signature of Main Member: __________________________
Date: ____/____/_____
Agent: _________________
Agent Code: _______ Signature: ______________ Date: ____/____/_____
MDALISU FUNERAL ADMINISTRATORS
Company Reg: 2014/158347/07
16th Foundale Groove
Newlands west, 4037
P O BOX 440
Durban
4000
C – 0837274919 F – 0867248850 E – [email protected] W- www.mdalisu.co.za
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