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Amazwi Funeral Services - Membership Application Form

1. Main Member Details

Full Names & Surname

ID Number

Date of Birth

Gender

A
B

Physical Address

Postal Address

Contact Number

Email Address

Marital Status

A
B
C
D

Occupation

Employer

2. Plan Selection

Please Select a Plan

A
B
C

Cover Amount Selected

Monthly Premium

3. Previous Funeral Policy (If Applicable)

Previous Funeral Provider

Policy Number

Date Policy Started

Date Policy Cancelled / Terminated

Waiting Period Completed?

A
B

Proof of Previous Cover Attached?

A
B

4. People to be covered (Up to 10 Members)

Full Names & Surname
ID Number
Date of Birth
Relationship
Gender (M/F)
1
2
3
4
5
6
7
8
9
10

5. Declaration

I, the undersigned, hereby apply for membership with Amazwi Funeral Parlour and confirm that the information provided in this application is true and correct. I agree to the terms, conditions, waiting periods and benefits as outlined in the policy.

I understand that this membership is subject to acceptance by the underwriter.
Signature of Main Member

6. Required Documents (Please attach)

Untitled checkboxes field