Funeral Cover Application

Personal Information

First Name

Surname

ID Number

Email Address

Contact Number

Preferred Contact Method

Street Address

Suburb

Town/City

Province

Postal Code

Employment Details

Employer Name

Occupation

Gross Monthly Salary

Product Information

Cover Amount

Budgeted Monthly Premium Note: While we will attempt to secure a premium closest to your budget, the final premium will depend on the risk assessment by the insurer.

Dependents

Add your dependents who need to be covered under this policy.

First Name	Surname	Date of Birth	Relationship	Cover Amount	Actions

No dependents added yet. Click "Add Dependent" to add one.

Dependent Details

First Name

Surname

Date of Birth

Relationship

Cover Amount

FICA Disclosures

I confirm that I am not a Domestic Prominent Influential Person (DPIP)

Consents

I consent to the processing of my personal information in terms of POPIA

I agree to the Terms of Service

I consent to MyBenefitz obtaining my information from Astute

I consent to a credit report check for affordability assessment

I would like to receive marketing communications from MyBenefitz