Take 10

RERIS take ten (10) - APPLICATION FOR MEMBERSHIP.

1. PRINCIPAL MEMBER DETAIL

First Name

Last Name

ID Number

Member Number

Employer Name

Marital Status

Phone/Mobile

Address

Address Line 1

Address Line 2

City

Province

Country Code

Country

2. Dependent's details

Depandant 1 Name

Depandant 1 Last Name

ID Number

Relationship

Depandant 2 Name

Depandant 2 Last Name

ID Number

Relationship

Depandant 3 Name

Depandant 3 Last Name

ID Number

Relationship

Depandant 4 Name

Depandant 4 Last Name

ID Number

Relationship

Depandant 5 Name

Depandant 5 Last Name

ID Number

Relationship

Depandant 6 Name

Depandant 6 Last Name

ID Number

Relationship

Depandant 7 Name

Depandant 7 Last Name

ID Number

Relationship

Depandant 8 Name

Depandant 8 Last Name

ID Number

Relationship

Depandant 9 Name

Depandant 9 Last Name

ID Number

Relationship

3. BENEFICIARY NOMINATION

First Name

Last Name

ID Number

Relationship

4. PRINCIPAL MEMBER PLUS 9 DEPENDANTS

FAMILY BENEFIT	OPTION A	OPTION B
Principal Member	R10 000	R15 000
9 Dependants	R10 000	R15 000
Total Premium Per Rate Per Month	R220,00	R320,00

5. Premium Calculation Summary

Full Family Benefit

Total Premium Due

6. Declaration

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. Safrican Insurance Company Limited (“Safrican”) 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 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 Safrican‘s offices for advice and assistance.

Date

7. Persal Deduction Authorisation

(Principal member must be the same person as the premium payer)

I, the undersigned:

First Name

Last Name

Rank

Station

ID Number

Department Code

Persal Number

I hereby authorise the Accountant of the Employer of to deduct from my salary each month the premium of R applicable for the cover selected with effect from and monthly thereafter, and pay this amount to Safrican Insurance Company Limited (Saftican from which I have obtained a policy, until such time as I cancel this authorisation in writing, or until I substitute it with a new authorisation.

Should the relevant premium rate be adjusted by Safrican as a result of increase in premium rate, I confirm that the adjusted premium rate may be deducted from my salary until such time as l cancel this authorisation in writing or until l substitute it with a new authorisation.

In the event of this deduction being dishonoured, the policy will lapse, subject to the grace period as stipulated under the terms and conditions. Deductions will not be accepted for arrears or any other premiums. I understand that this signed document is required in the Safrican offices prior to the deduction date; if not, the deduction will only qualify for the following calendar months‘ deductions, and will only commence the following month. Please allow for 6 (six) weeks for your policy to be deducted and loaded.

8. Debit Order Authority

I hereby authorise Safrican Insurance Company Limited (“Safrican") to commence a debit order withdrawal from my account on the 1st unless specified otherwise on day of the month and monthly thereafter, with any future possible increase on the product.

I understand that the debit order will be run on the date selected; if for whatever reason it is not honoured, the policy will lapse subject to the grace period as stipulated under the terms and conditions. I understand that this signed document is required in the Safrican offices (ten) working days prior to the elected deduction date; if not, the deduction will only qualify for the following calendar month’s deductions, and cover will only commence the following month.

First Name

Last Name

8. Debit Order Authority

First Name

Last Name

Bank Name

Account Number

Branch Name

Branch Code

Account Type

Deduction Date

SUMMARY OF the TERMS AND CONDITIONS for RERIS Family Cover Scheme

FUNERAL AID BENEFITS

If the Insured or his/her Family Member dies, the funeral aid benefit as selected on the application form and confirmed in the participation certificate, is paid.

Insured

The Insured or Principal Member is any client of Reris under the ages specified below at the time of applying for the insurance, is insured in terms of the policy:

62 years in the case of an Insured with Family Members
84 years in the case of an insured without Family Members

On the understanding that an Insured without Family Members must be older than 60 years to qualify for the insurance.

Family Member

Qualifying Spouse, Qualifying Child and Extended Family Member.

Marriage

A marriage/union in accordance with the Marriage Act, 1961, the Recognition of Customary Marriages Act, 1998, the Civil Union Act, 2006 or in terms of the tenets of a religion. Also includes a union where two persons live together as if married with the commitment of continuing to do so permanently and have been doing so for at least 6 months, provided they have successfully applied in writing to Safrican far the Union to be registered and one or both of them are not joined in a marriage or union with another person.

Qualifying Spouse

The person with whom the Insured is joined in Marriage (as defined above), who is over the age of 15 years and under the age of 62 years at the time of applying for insurance and which has been nominated in writing to Safrican, will be the Quantifying Spouse. If the Insured failed to nominate a Qualifying Spouse, the first spouse with whom he/she was joined in Marriage, will be the Qualifying Spouse.

Qualifying Child

Unmarried child of the Insured or his/her Qualifying Spouse under the age of 22 or unmarried child who is a full time student under the age of 26 (proof of study must be supplied) or unmarried child, irrespective .of age, who is in capacitated by a physical or mental infirmity and unable to maintain himself/ herself.

Stillborn Child

A child of the Insured or his/her Qualifying Spouse that has had at least 26 weeks of intra-uterine existence but showed no sign of life after complete birth.

Qualifying Parent

The Insured’s/Qualifying Spouse’s father, mother or foster-parent or such

person’s spouse, who is under the age 75 at the time of applying for the insurance and is nominated in writing by the Insured and for wham an additional monthly premium is paid as determined by Safrican.

PREMIUMS

A premium per Insured, determined by Safrican, is payable monthly in advance. If any premium is not paid timorously, Safrlcan’s liability in terms of the policy regarding that Insured and his/her Family Members lapses. One month's written notice shall be given in advance of effecting the rate change.

Premium increase will be determined by claims ratio.

FICA VALIDATION:

The validity of this insurance policy is subject to the fulfilment of due diligence obligations of the Insurer and Service Provider under the provisions of the Financial Intelligence Centre Act (as amended) conducted on the Identity of client(s) or persons acting on behalf of clients as well as beneficiaries, and beneficial owners of juristic persons where applicable.

PURPOSE FOR PROCESSING YOUR INFORMATION

Your information will only be used for the purpose you would reasonably

expect, including; providing administrative services on behalf of your Insurer and Service Provider, to issue, administer and manage your insurance policies, to process insurance claims, to notify you, on behalf of your Service Provider, of new products or developments that may be of interest to you, to verify your identity and to confirm, verify and update your details, and to comply with any legal and regulatory requirements.

CONSENT TO DISCLOSE AND SHARE YOUR INFORMATION:

Your information may need to be shared to verify your identity, provide advice, reports, analyses, products or services that you have requested. Where we share your information, we will take all precautions to ensure that the third party will treat your information with the same level of protection as required by us.

EXCLUSIONS

Certain exclusions with regards to war and terrorism apply. Certain limitations may apply if you are not physically present in the Republic of South African. If you are going to be outside the borders of the Republic of South African for a period longer than 6 months, please inform the

administrator immediately.

WAITING PERIOD

In the case of death due to natural causes, any cover or any increase in cover has a waiting period of 6 {six} months from date of commencement or date of increase as the case may be. If the insured ‘s or Family Member's benefit have lapsed and he/she again becomes insured in terms of the policy, the above waiting periods will apply.

BURIAL REPATRIATION BENEFIT

This benefit is available on the death of any Insured or Family Member at no charge. The benefit provides for transport of the deceased via read or air from anywhere in South Africa, Lesotho, Swaziland, Zimbabwe, Botswana, Namibia or Mozambique (south of the 22° latitude}, to the funeral home closest to the place of burial in South Africa. One relative may accompany the body to the funeral home, and if needed, overnight accommodation {one night) will be provided at no additional cost.

CALL: 011 778 8000- Provide the following information:

Name and identity number of the deceased
Name and code of the scheme
Place where death occurred

RIGHT TO CANCEL

The Insured may at any time cancel the policy. This policy is a risk only policy and as such has no cash benefit and there will be no refund on premiums in respect of cover already enjoyed.