Pukwana ya Kganya Terms & Conditions

20 Annexe A.2 Member’s Personal Particulars Form 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 Employment Status Cell No Alt. Cell No New Replacement Continuation D D M M Y Y Y Y Gender Please tick M F Control Number SA Membership Book Purchase Price R90-00 South Africa Country of Residence Country of Birth Nationality Surname First Name Identity No Cell No Beneficiary for funeral benefit (information required for Insurance Contract) (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 theTrust, 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 theTrust (either itself or through third parties) Y Y Y N Y N Employed Self-employed Unemployed Pensioner D D M M Y Y Y Y Date Completed Signature of Member / Policyholder