Application Form

NH Funeral Scheme Application Form

1. Insurance Information Previous Funeral Insurance:
Name of existing underwriter:
Existing policy number:

2. Principal Member Details Title:

Full names:

Surname:

Date of Birth:

Current Age:

SA ID Number:

Passport Number (if applicable):

Country of Birth:

Country of residence:

Nationality:

Marital status:
If you are not the paying the premiums of the policy, please provide the details of the policy payer:

Policy Payer Name And Surname:

Policy Payer ID number:

Source of Income:

If other please describe:

3. Contact Details Postal address:

Postal code:

Residential address:

Postal code:

Tel. no (H):

Tel. no (W):

Cell no:

Email:

4. Qualifying Co-insured

Surname:

Name:

ID number:

Relationship:

5. Cover required Cover required:
Cover Amount:

Benefit plans and premium per month per plan – Please select your choice of plan

SINGLE

Age at Entry	R10 000	R15 000	R20 000	R30 000
18 to 64 years	R77.50	R91.15	R111.10	R136.00
65 to 74 years	R150.10	R194.50	R248.90	R342.70
75 to 84 years	R236.55	R324.18	R421.80	R602.05

Single Parent

Age at Entry	R10 000	R15 000	R20 000	R30 000
18 to 64 years	R82.05	R97.98	R134.54	R159.44
65 to 74 years	R159.65	R221.33	R272.34	R366.14
75 to 84 years	R246.10	R331.00	R445.24	R625.49

Family

Age at Entry	R10 000	R15 000	R20 000	R30 000
18 to 64 years	R122.50	R149.65	R179.10	R253.00
65 to 74 years	R246.65	R337.83	R430.00	R629.35
75 to 84 years	R424.40	R605.95	R787.50	R1 166.60