PYK Payment Receipt Booklet

9 MEMBERS PERSONAL PARTICULARS By completing this MPP Form you i) accept the offer for insurance by the Insurer* in terms of the Insurance Contract; and ii) agree to be bound to the terms of Membership to the Trust and the terms of the Insurance Contract, as explained in the Membership Terms and Conditions Booklet. Please complete this form in black ink, using block letters, one letter per block. Membership No Church Name Church Code Surname First Name Identity No Date of Birth Cell No Alt. Cell No New Replacement Continuation Gender Please tick Control Number SC Membership Book Purchase Price R90-00 South Africa Surname First Name Identity No Cell No Beneficiary information for Funeral Benefit (Primary cellphone number) (Secondary cellphone number) In applying to become/continue as a Member I confirm (tick relevant block) that: • I have read and agreed to the Declaration as stated on page 5 of this Payment Receipt Booklet • I am aware that the details of the Privacy Policy of the Trust, KIAand the Insurer are contained on page 6 of this Payment Receipt Booklet and commit to familiarising myself with its contents • I have cancelled a funeral policy in the last 31 days with another insurer which offered similar funeral/burial benefits under the Insurance Contract • I wish to be informed of other products made available by the Trust (either itself or through third parties) Y Y Y N Y N Date Completed Signature of Member / Policyholder * Sanlam Developing Markets Limited • Registration No: 1911/003818/06 • FSP No: 11230 • PO Box 1941, Houghton, 2041 • Sanlam, 9 -13 West Street, Houghton, Johannesburg, 2196 Tel: 0861 235 433 • Email: gbcentre@sanlamsky.co.za • Website: www.sanlam.co.za D D M M Y Y Y Y D D M M Y Y Y Y M F