Broker Recon System

Policy Holder Details

Select Application Type:

Select Scheme Option:

Region :

Cell Number :

Email :

APPLICATION FOR VOLUNTARY FUNERAL ASSURANCE WITH EXTENDED FAMILY BENEFITS

Region :

Station :

Department :

Surname :

Name :

ID Number :

Age :

UMNGCWABO :

Cell Number :

Work Number :

Premium :

Email :

SAPU Number :

Postal Address :

Residential Address :

Next Step

PERSONAL DETAILS OF SPOUSE:

Surname :

First Name :

ID Number :

UMNGCWABO :

Premium :

PRINCIPAL MEMBER’S OWN CHILDREN DETAILS:

Name:	ID Number:	UMNGCWABO:	Preminum:






TOTAL IMMEDIATE FAMILY PREMIUM:

WIDER CHILDREN’S DETAILS:

Name:	ID Number:	Premium:




TOTAL WIDER CHILDREN PREMIUM:

EXTENDED FAMILY DETAILS:

Name:	ID Number:	REPATRIATION PREM	UMNGCWABO	COVER AMOUNT	PREM	TOTAL PREM




TOTAL EXTENDED FAMILY PREMIUM

Repatriation benefit for extended family members can be added @ R2.30 per member.

Next Step

CONSENT QUESTION

TITLE :

NAME :

PASSPORT NUMBER :

SURNAME :

PERMIT NUMBER :

I.D NUMBER :

NATIONALITY:

BANK NAME :

MARITAL STATUS :

ACCOUNT NUMBER :

PHYSICAL NUMBER :

Next Step

DETAILS OF CO-INSURED AND OTHER INSURED

TITLE :

NAME :

PASSPORT NUMBER :

SURNAME :

PERMIT NUMBER :

I.D NUMBER :

NATIONALITY:

BANK NAME :

MARITAL STATUS :

ACCOUNT NUMBER :

PHYSICAL NUMBER :

CONFIRM

Concent Question

“To enable the insurer to underwrite risk fairly and to combat insurance fraud, we need to have your consent to verify and share policy information with insurers and other institutions as well as to access credit information held by other institutions.

Do you give the insurer consent?