OTP TEST PAGE – Kunene Makopo Funeral

DETAILS OF MEMBER

Selected the option that is applicable to you *

New Application
Existing Client

Name

First

Last

ID Number *

Work Telephone Number

Address *

City *

Postal Code *

EXECUTIVE FAMILY COVER

Your Spouse's Name

First

Last

Your Spouse's ID Number

_____________________

Your 1st Child's Name

First

Last

Your 1st Child's ID Number

_____________________

Your 2nd Child's Name

First

Last

Your 2nd Child's ID Number

_____________________

Your 3rd Child's Name

First

Last

Your 3rd Child's ID Number

_____________________

Your 4th Child's Name

First

Last

Your 4th Child's ID Number

_____________________

Your 5th Child's Name

First

Last

Your 5th Child's ID Number

_____________________

Your 6th Child's Name

First

Last

Your 6th Child's ID Number

_____________________

Your 7th Child's Name

First

Last

Your 7th Child's ID Number

_____________________

What is the beneficiaries' name? *

First

Last

What is your relationship to the beneficiary? *

What is the beneficiaries' ID number? *

What is the beneficiaries' cellphone number? *

What is the beneficiaries' email address? *

YOUR BANKING DETAILS

Bank *

Account Number *

Branch Code

Account Type *

Savings
Cheque
Transmission

Premium *

R70
R124
R140

Do you authorize Kunene Makopo Risk Solutions or Mandated Party ("Netcash/"Sagepay") to commence a debit order withdrawal from my account? *

Yes, I authorize.

Please select the day that will be the 1st monthly debit order for your cover? *

Do you understand that there is a possible percentage increase each year, for the premium applicable for the cover selected? *

Yes, understand.

On which day do you prefer your debit order to be in the month of December?

Do you 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? Do you understand and agree that this signed Authority and Mandate refers to our contract dated on the day that this form / contract was completed and submitted (“the Agreement”). You hereby authorise Kunene Makopo Risk Soultions to issue and deliver payment instructions to your Banker for collection against your above-mentioned account at your above-mentioned Bank (or any other bank or branch to which you may transfer you account) on condition that the sum of such payment instructions will never exceed your obligations as agreed to in the Agreement and commencing the date that you chose and continuing until this Authority and Mandate is terminated by you by giving us notice in writing of not less than 20 ordinary working days, and sent by prepaid registered post, email or delivered to your address as indicated above. *

Yes, I understand, agree and authorise.

Do authorize that the individual payment instructions to be issued must be issued and delivered mothly? *

Yes, I understand and agree.

Do you understand and agree that, in the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the preceding ordinary business day? Do you understand that the withdrawals hereby authorized will be processed through a computerized system provided by the South African Banks and you also understand that details of each withdrawal will be printed on your bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. Do you understand that a payment reference is added to this form before the issuing of any payment instruction? *

Yes, I understand and agree.

PERSAL DEDUCTION AUTHORIZATION

Do you grant permission for Old Mutual to arrange with your employer for payment of my premiums, including increases that may be made during the life of the policy. Do you grant permission for Old Mutual to gather information from my employer or third parties to facilitate the payment process? Do you understand that the first deduction from your salary will start at the end of next month or as soon as possible thereafter but within 3 months of signing this form? Are you aware that your request can be declined should your employer not give consent to do this deduction from your salary? Do you confirm that the information you have provided is complete and correct? Do you authorise the Accountant of the Department/Administration of Kunene Makopo Risk Solutions to deduct from your salary each month applicable for the cover selected with effective from the end of this month? Do you understand that it is from Old Mutual that you are obtaining your policy from? Do you understand that it is until such time as you cancel this authorization in writing, or until you substitute it with a new authorization?

Yes, I understand and confirm all of the above.

On which day of the month would you like pay this amount to Old Mutual?

Please sign your signature in the box below with your finger or mouse cursor.

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.

CLAIMS PROCEDURE

Do you understand that the specified benefits will be paid to the beneficiary, the estate of the member, or on request of the beneficiaries to the administrator at the death of the assured, who in shall pay the benefits to the person/s legally entitled thereto? Do you understand that claims must be reported to The Administrator within 6 (six) months of the death of the assured? Do you understand that the insurer and Kunene Makopo reserves the right to cancel the policy and to declare all premiums paid by the policyholder in terms of the policy forfeited. If there is any evidence of or attempted submission of a fictional claim, or fraud or mirepresentation?

Yes, I understand.

Do you understand that claims must be accompanied by 7 (seven) documents, which are: (1) an official or certified copy of the original death certificate, (2) a certified copy of the deceased's and beneficiary's ID documents, (3) a police statement in case of death due to unnatural causes, (4) certified copy of the BI 1663 The Administrator may reauest additional documentation from time to time, (5) an affidavit by the claimant confirming dependency of deceased, (6) policyholder membership certificate and bank details and (7) permission of the beneficiary for deposit of benefit?

Yes, I understand.

Our complaints resolution policy can be obtained by contacting the complaints officer as detailed on the disclosure document.Complaints which are not resolved to your satisfaction may be referred to: Particulars of Long-term Insurance Ombud at: Registrar of Long-term Insurance at: Private Bag X45, Claremont, 7735 __________ TEL(021) 657 5000 __________ FAX (021) 674 0951 __________ PO Box 35655, Menlopark __________ Tel (012) 428 8000 __________ Particulars of FAIS Ombud at: Mr Charles Pillai ___________ P O Box 74571, Lynnwood Ridge, 0040 __________ TEL: (012) 470 9080/99 _________ FAX: (012) 348 3447

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? 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.

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.

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.

Cellphone Number *

Message

Cookie	Duration	Description
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.