Khanyisa | Edit Lead

PRINCIPAL MEMBER DETAILS

Application Type:

Select Scheme Option:

Region :

Cell Number :

Email :

APPLICATION FOR VOLUNTARY FUNERAL ASSURANCE WITH EXTENDED FAMILY BENEFITS

Region :

Station :

Policy Number :

Surname :

Name :

ID Number :

Age :

UMNGCWABO :

Cell Number :

Work Number :

Premium :

Email :

SAPU Number :

Postal Address :

Residential Address :

Status :

Status

PERSONAL DETAILS OF SPOUSE:

Surname :

First Name :

ID Number :

UMNGCWABO :

Premium :

PRINCIPAL MEMBER’S OWN CHILDREN DETAILS:

@foreach($oc as $data) @endforeach

Name:	ID Number:	UMNGCWABO:	Preminum:

TOTAL IMMEDIATE FAMILY PREMIUM:

WIDER CHILDREN’S DETAILS:

@foreach($wc as $dataa) @endforeach

Name:	ID Number:	Premium:

TOTAL WIDER CHILDREN PREMIUM:

EXTENDED FAMILY DETAILS:

@foreach($ef as $dataa) @endforeach

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

TOTAL EXTENDED FAMILY PREMIUM

INCOME CONTINUATION BENEFIT:

@foreach($ib as $dataa) @endforeach

BENEFIT PER MONTH	PREMIUM

TOTAL PREMIUM CALCULATION

Total Immediate Family Funeral Premium + Umngcwabo / Beef / Inkomo Premium
Wider Children Premium
Extended Family Premium
Income Continuation Premium (6 Months)
Airtime Premium
Car Hire Premium
GRAND TOTAL PREMIUM

BENEFICIARY NOMINATION

I hereby nominate the following person for any benefits due to be paid from the scheme in the event of my death

NAME:

SURNAME:

ID NUMBER:

RELATIONSHIP:

PREMIUM PAYMENT

NAME :

SURNAME:

RANK:

STATION:

I.D NUMBER :

PERSAL NUMBER:

AMOUNT:

START DATE:

DEBIT ORDER AUTHORITY

ACCOUNTHOLDER NAME:

BANK NAME:

BRANCH NAME:

ACCOUNT NUMBER:

BRANCH CODE:

AMOUNT:

ACCOUNT TYPE:

START DATE:

Add Task

Reminders / Tasks

ACTION	DATE	CLIENT NAME	ASSIGNED TO	POLICY TYPE	DUE DATE
LETTER OF DEMAND	2019-02-10	Jemy Forbay	Jemy Forbay	Personal Lines	2019-02-17
LETTER OF DEMAND	2019-02-10	Jemy Forbay	Jemy Forbay	Personal Lines	2019-02-17

Communication

ACTION	DATE	ASSIGNED TO	DEADLINE
LETTER OF DEMAND	2019-02-10	Jemy Forbay	2019-02-17
LETTER OF DEMAND	2019-02-10	Jemy Forbay	2019-02-17