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Marindi Funeral Scheme Application
Complete the form, sign in the signature boxes, then press Submit Application. When hosted with the PHP files, the application will be saved to the database and emailed to applications@marindifunerals.co.za.
APPLICATION FORM
Referral Details
Referred By (Sales Rep/Admin)
Section A: Personal Details
Membership No
Title
Initials
Gender
ID Number
Age
First Name
Surname
Cell No
Work No
Address
Postal Code
Occupation
Employer
Spouse Details
Title
Initials
Gender
ID Number
Age
First Name
Surname
Email
Section B: Dependants
Full Name
Relationship
ID Number
Full Name
Relationship
ID Number
Add Dependant
Section C: Extended Dependants
Full Name
Relationship
ID Number
Add Extended Dependant
Section D: Beneficiary
National Identification Number
Initials
First Names
Surname
Gender
Cell No
Work No
Section E: Benefit Details
Age (Policyholder)
Age (Spouse)
Premium (R)
Cover Amount
Extended Premium
Total Premium
Start Date
Terms and Conditions
You give Marindi Funeral Scheme permission to instruct your bank to collect premiums from the bank account above, or any other bank you might transfer to in future. You agree to the following conditions: 1. We'll never debit more money from your bank account than the premiums you've agreed to in your contract with us; 2. You understand that the bank will treat Marindi Funeral Scheme's payment instructions as if you've issued them; 3. We'll debit your account monthly on your chosen debit order date. If the payment day falls on a Sunday or a recognised South African public holiday, we'll debit your account on the next work day; 4. The start date of this instruction is subject to the activation of your policy; 5. The withdrawals you've authorised will be processed through a computerised system provided by South African banks; 6. The details of each withdrawal will be printed on your bank statement, with your policy number as a reference. You must end this authority in writing This authority will be valid until you end it in writing By registered post: PostNet Suite #280, Private Bag 30500, Houghton, Gauteng, 2041 By hand delivery: 165 West Street, Sandton, Gauteng, 2146 You must give us at least 20 ordinary working days' notice before ending this authority. Ending this authority does not end our agreement with you If you cancel this agreement, you understand that: 1. Cancelling this authority and mandate will not cancel our agreement; 2. If you legally owe us money, you won't be entitled to any refund of any amounts that we've debited while this authority was in force. If our agreement with you is transferred (ceded or assigned) to a third party, this authority will be transferred too. You acknowledge that, if we cede or assign our agreement with you to a third party, this authority and mandate will also be ceded or assigned to the third party. This authority and mandate can only be assigned to a third party if the agreement between us has also been assigned to that party.
Section F: Payment Method
Debit Order
Cash
Bank Name
Account Holder
Account Number
Branch Code
Account Type
Preferred Debit Day
Signatures
Main Member Signature
Account Holder Signature
Date
Policy Replacement
Replacing existing policy?
Yes
No
Submit Application
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