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Residential address Postal address Do you require funeral cover for your immediate family?
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Particulars of benefits
d d m m y y
Plan C
Plan D
Plan E
Plan
R R 3.50 R
Identity number
Relationship
Benefit %
Signature of member
Date
m m
m m
Amount to be deducted
Premium deduction source and other particulars. I authorize my employer to deduct the premiums from my salary and to pay it to Assupol Life. If the premium changes for any reason in terms of policy or agreement between Assupol Life and the policyholder, Assupol Life likewise may deduct the premium from my salary. If payment cannot be done on the preferred payday of the month filled in above, it must be done on a day that is as close as possible to that day, determined by the employer. If the policy ends. I may cancel, amend or replace this authorisation by written notice to my employer. I accept that my employer must receive notice not later than 30 days before the month from which the cancellation, amendment or replacement is to apply. I have read, understand, and agree with the above payment authorisation. Signature of premium-payer Date
m m
Underwritten by
Life Limited
Assupol Life Ltd reg no 2010/025083/06 Authorised financial services & credit provider Head office 308 Brooks street, Menlo Park, Pretoria, 0081
I authorize Assupol Life to draw the premiums from my bank account. If the premium changes for any reason in terms of the policy or by agreement between Assupol Life and the policyholder, Assupol Life likewise may draw the changed premiums from my bank account. If payment cannot be done on the preferred payment date filled in below, it must be done on a day that is as close as possible to that day, determined by Assupol Life. If the policy ends, this authorization also ends. I may cancel, change or replace this authorization by written notice to Assupol. I accept that Assupol Life must receive the notice not later than 30 days before the month from which the cancellation, change or replacement is to apply Signature of premium-payer Date
m m
m m
Declaration by intermediary
Surname Initials ID number
(1) I have not and will not give money or anything of value to the applicant or a person whose life is to be insurance as an inducement to take out the insurance, and I have not in any way misled the applicant or such other person about any aspect of the insurance. As far as I know no-one else has done or will do any of these things. (2) I have explained to the applicant the meaning and implications of replacing insurance, and I am fully aware of the possible detrimental consequences of replacing insurance. Signature of intermediary Intermediary code Date
m m
Underwritten by
Life Limited
Assupol Life Ltd reg no 2010/025083/06 Authorised financial services & credit provider Head office 308 Brooks street, Menlo Park, Pretoria, 0081