Extended family Cover Application

EXTENDED FAMILY COVER

Please note that you cannot take the Extended Cover if you do not have Executive Family Cover.

Take you time to think about all your extended family members and what a big difference you can make in their lives with your KM Funeral Premiums.

Use our premiums calculator to work out how much you can afford per month, for all your family.

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Step 1 of 7

1. DETAILS OF MEMBER

What is your Policy Number *

This policy number is from your current Executive Family Cover with Kunene Makopo Risk Solutions. You need this number to proceed. Go to the menu a select Executive Family Cover to begin.

Name *

First

Last

ID Number *

Cellphone Number *

Work Telephone Number

Address *

City *

Postal Code *

MANDATE

Do you acknowledge that all payment instructions issued by you shall be treated by your above-mentioned Bank as if the instructions have been issued by you personally? *

Yes, I acknowledge.

CANCELLATION

Do you agree that although this Authority and Mandate may be cancelled by you, such cancellation will not cancel the Agreement and that you shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you? *

Yes, I agree.

ASSIGNMENT

Do you acknowledge that this Authority may be ceded 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? *

Yes, I agree.

From where are you signing this contract from? *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

What is the signature date? *

Date

Time

If you are about to complete and sign today, then enter today's date.

Confirm your name *

First

Last

With the tip of your finger, please sign your signature in the box below. *

You will recieve a call from one of our friendly administrators to confirm your application. The Agreement reference number will be emailed to you and once you press submit.

RIGHT TO CANCEL

Do you understand that after the Insurer has accepted your application for assurance, you may, if you decide, instruct the Administrator to cancel your policy and refund your premiums. *

Yes, I understand.

This instruction must be submitted in writing, via mail or email, to the administrator within 30 (thirty) days after receipt of the membership certificate. You amy only submit such a cancellation instruction if no benefits have been paid or claimed or an event insured against has not yet occured.

Do you understand that the Administrator may deduct the cost of any risk cover you enjoyed under the policy before it was cancelled? *

Yes, I understand.

DISCLOSURE DOCUMENT

Do you acknowledge that as a long-term insurance policyholder, you have the right to the following information? *

Yes, I acknowledge.

(Please retain a copy of this Disclosure Document for your records) Product Supplier (Insurer) with whom your policy is placed. __________ Company Name: Old Mutual Insurance Company Limited __________ Physical address: Mutualpark, Jan Smuts Drive, Pinelands, 7405, South Africa __________ Fax: 021 509 3181 __________ Email: GSFMQueries@oldmutual.com __________ Postal address: P.O BOX 73, Cape Town, 8000 , South Africa __________ Telephone Number: (021) 509 9111 __________ Website:www.oldmutual.co.za

MANDATED INTERMEDIARY

Do you acknowledge that Kunene Makopo Risk Solutions is licenced as a Financial Services Provider, entitled to provide advice and intermediary services on your behalf in respect of the policy underwritten by Old Mutual Life Assurance Company Limited as product supplier? *

Yes, I acknowledge.

Compliance Officer: Ruby Mosime - Mosime Consult - Compliance Practice No, 7011, Mobile: 084 290 2833

CONFIRMATION

(1) Do you understand and agree that the consequences and importance of accurate disclosures of all material facts. __________ (2) Do you understand and agree that all fields on this form were fully completed digitally by you (as per your full names on this "agreement") before you signed them? __________ (3) Do you understand and agree that you have been made aware of the contents of all documents used in the purchase of this policy? __________ (4) Do you understand and agree that this policy does/does not replace an existing life (funeral) policy? Do you understand and agree that if it does, I have completed the required additional paperwork and that the consequences of policy replacement have been explained and understood? __________ (5) Do you understand and agree that product is sold to you on a non-advisory basis and that for advise you can contact Kunene Makopo Risk Solutions on +27 (0) 10 900 1346? __________ (6) Do you understand and agree that you are fully aware of the waiting period provisions of this policy? _________ (7) Do you understand and agree that you are fully aware of the premium payment provisions and consequences of non-payment of this policy and that a debit order/salary deduction form has been completed and signed by member? __________ (8) Do you understand and agree that you hereby apply for the benefits contained in this document and you have declared that you have not withheld and material information? __________ (9) Do you understand and agree that this application and declaration shall be the bases of the contract between you, Kunene makopo Risk Solutions and Old Mutual Life Assurance Company? __________ (10) Do you understand and agree that you further appoint Kunene makopo Risk Solutions as your mandatory broker to amend, cancel and transfer my policy for your benefit? _________ (11) Do you understand and agree that any willful misrepresentation in application will invalidate any benefit under this Policy and all premiums paid will be forfeited in this event? __________ (12) Do you understand and agree that you undertake to abide by the terms and conditions of the Policy? __________ (13) Do you understand and agree that the insurer shall not be liable for any amount until it has accepted this application and first premium? __________ (14) Do you understand and agree that the premium withdrawals hereby authorised will be processed by persal or debit order and that you agree to pay any bank charges related to this debit order instruction? _________ (15) Do you understand and agree that this authority may be cancelled by you giving the Insurer 30 days’ notice in writing but you understand that you shall not be entitled to any refund of amounts which have been withdrawn while this authority was in force if such amounts were legally owing to the Insurer? _________ (16) Do you understand and agree that you hereby grant permission that the premium may be deducted against your monthly salary on a monthly basis or against your bank account on a monthly basis until you cancel this authorisation in writing or substitute it with a new authorisation? _________ (17) Do you understand and agree that you have been informed of your rights in terms of the Policyholder Protection Rules and that you declare that you have read and understood the terms and conditions attached to this policy? *

Yes, I understand and agree.

Do not want to receive any special promotions from Kunene Makopo Risk Solutions by sms, telephone, e-mail or post? *

From where are you signing this contract from? *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

What is the signature date? *

Date

Time

If you are about to complete and sign today, then enter today's date.

Confirm your name *

First

Last

Signature *

United States US VA Ashburn 39.0438 -77.4874 America/New_York Amazon.com, Inc.

Protection of Personal Information Act *

I hereby consent to the processing of the personal data that I have provided and declare my agreement with the data protection regulations in the data privacy.

Name

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