Application for Funeral Cover

Embrace Legacy

LEGACIES EMBRACED

DIGITAL FUNERAL POLICY APPLICATION
Authorised Financial Services Provider — FSP 53892
Cover underwritten by Guardrisk Life Ltd — FSP 76

Step 1 of 14

Important: Please complete the application accurately. Incorrect or incomplete information may affect the policy or future claims.

1. Select Your Cover

Choose your family structure, age and plan. Your monthly premium will calculate automatically.

Is this a replacement policy? * Are you an existing policyholder? *

Who would you like to cover?

Single Main member only

Member + Spouse Two adults

Member + Children Up to 6 children

Family Member + spouse + children

Main Member Age *

Choose Your Plan

Standard R10,000 main cover

Deluxe R20,000 main cover

Superior R30,000 main cover

Prestige R50,000 main cover

Your Estimated Monthly Premium

Change your cover options above and your premium will update instantly.

Monthly Premium

R31 / month

≈ R1.03 per day

Standard — Single R31

Main Member: R10,000

This age and cover combination is not available. Please choose a different extended-family option.

2. Principal Insured

The Policyholder and Principal Insured are the same person.

Title Initials Date of Birth * ID / Passport Number * Gender * Full Name * Surname * Marital Status Citizenship Country of Birth Country of Residence Nationality Physical Address * Postal Code Email Cell Phone * Source of Income Employer Occupation Industry

3. Spouse

Complete this section if your selected cover includes a spouse.

Title Initials Date of Birth ID Number Full Name Surname Gender

4. Children

Add up to six children.

ID / Birth Certificate	Full Name	Relationship	Gender

5. Extended Family

Add extended family members. Their individual premiums are added automatically to your monthly premium.

ID Number	Full Name	Relationship	Gender	Age Band	Cover

6. Beneficiary

Full Name * Surname * ID Number * Date of Birth * Relationship * Contact Number * Beneficiary Percentage *

7. Debit Order

Name of Bank * Account Number * Branch Code Account Holder * Account Type * Monthly Debit Amount * Debit Date *

I authorise collection of the applicable policy premium from the nominated account.

8. Marketing Consent

Receive policy benefit information? Receive product information?

9. POPIA Consent

Personal information supplied through this application may be processed for identity verification, policy administration, fraud prevention, legal compliance and related insurance purposes.

Information may be shared with relevant insurers, administrators, financial institutions, regulators and authorised service providers where reasonably required.

I consent to the processing of my personal information for this application and policy administration.

10. Record of Advice

Cash Benefit

The funeral benefit is payable in cash subject to policy terms.

Cooling-Off Period

A 31-day cooling-off period applies.

Waiting Period

A six full month waiting period applies to natural death. Accidental death is covered immediately provided the first premium is paid in full.

Suicide

Suicide is excluded during the first 12 months.

First Premium

The first premium must be honoured for the policy to incept.

Claims

Claims remain subject to the applicable policy terms and claims requirements.

I confirm that the important policy terms have been explained to me and I understand them.

11. Other Disclosures

Underwriting Manager

Ongeza Life (Pty) Ltd.

Broker

Embrace Legacy (Pty) Ltd.

Administrator

Ness Consulting (Pty) Ltd.

I confirm that the applicable disclosures have been explained to me.

12. Supporting Documents

Upload or photograph the required documents.

Principal Member ID * Spouse ID Children's IDs / Birth Certificates Extended Family IDs

13. FICA & Influential Person Declaration

Politically Exposed Person Domestic Prominent Influential Person Foreign Prominent Public Official Known Close Associate Family Member Reason / Details

14. Representative & Declaration

Representative Details

Representative Full Name * Brokerage Representative ID * FSP Number Email Cell Phone *

I confirm that the benefits, premium, debit date and relevant policy information were explained to the applicant.

Applicant Declaration

I confirm that the information supplied in this application is true and complete.

I understand that incorrect or withheld information may affect the policy or future claims.

I accept this declaration and agree to sign electronically.

Policyholder Signature *

Full Name of Signatory * Date *