Dignity Group

FAMILY FUNERAL PLAN

Details of policyholder
ID number Surname Full first names Tel no (W) Tel no (H) E-mail Residential address Province Postal address Province Main occupation Monthly salary (Gross) Postal code Postal code ( ( ) ) Title Ethnic group Marital status Cellular Fax ( ) Initials Black Single Gender Coloured Married Male Indian Divorced Female White Widowed

(This information will only be used for statistical purposes)

Details of spouse
ID Number Surname Title Full first names Initials Gender Male Female

Details of dependant children

Surname Full names Date of birth d d m m y d d m m y d d m m y d d m m y d d m m y y y y y y y y y y y y y y y y Age Gender

1. 2. 3. 4. 5.

Details of extended family members

Surname Full names Relationship Date of birth d d m m y d d m m y d d m m y d d m m y d d m m y y y y y y y y y y y y y y Cover y y R R R R R Premium R R R R R R

1. 2. 3. 4. 5.

Total premium

Nominated beneficiary
Title Initials Surname Identity number Relationship

I, the applicant / member under this policy, hereby nominate the above mentioned person as the beneficiary in terms of this policy, to receive all benefits payable under this policy. I hereby indemnify Assupol Life against any claim by myself or my relatives / estate in respect of the payment of the policy benefits to the nominated beneficiary.

Details of benefits
Family funeral plan
Plan A Family 18 - 65 years Monthly premium R 5 000 R60.00 Plan B R 6 000 R70.00 Plan C R 7 500 R80.00 Plan D R10 000 R90.00 Family 66 - 75 years Monthly premium Plan E R 5 000 R140.00 Plan F R 6 000 R180.00 Plan G R 7 500 R160.00 Plan H R10 000 R170.00

Single funeral plan

Plan I Member 18 - 65 years Monthly premium R 5 000 R50.00 Plan J R 6 000 R60.00 Plan K R 7 500 R70.00 Plan L R10 000 R80.00 Member 66 - 75 years Monthly premium Plan M R 5 000 R110.00 Plan N R 6 000 R120.00 Plan O R 7 500 R130.00 Plan P R10 000 R140.00

Plan Q Member 76 - 85 years Monthly premium R 5 000 R160.00

Plan R R 6 000 R170.00

Plan S R 7 500 R180.00

Plan T R10 000 R190.00 Member 85+ years Monthly premium

Plan U R 5 000 R190.00

Plan V R 6 000 R200.00

Plan W R 7 500 R210.00

Plan X R10 000 R220.00

Underwritten by

Life Limited

Head office 308 Brooks street, Menlo Park, Pretoria, 0081 Assupol Life Limited reg no 2010/025083/06 An authorised financial services & credit provider

Details of benefits continued

Extended Family Member's Age 0 - 13 Years 15 - 30 Years 31 - 50 Years 51 - 65 Years Funeral Plan Option selected Extended Family Benefit Debit Order Fee (R3.50 payable should the premium be paid by debit order) Total monthly premium Charge Per R 1 000 R 3.00 R 4.00 R 7.00 R 9.00 Plan Extended Family Member's Age 66 - 70 Years 71 -75 Years 76 - 80 Years Charge Per R 1 000 R12.00 R18.00 R25.00 R R R R

Employment and stop order details (all sections must be completed)

Premium deduction source Employment sector Payday Date of first deduction Y Y Y Y Method of payment Employee number/ temporary Persal number - For stop order payments. If client gets paid on the same date every month e.g. 25 or 27. M M D D Amount to be deducted Persal Other stop order Debit order

Premium deduction authorisation

I authorise the accounting officer of my employer to deduct from my salary the premium as indicated above and pay it over to Assupol Life. I would like the day of deduction as indicated to be used, or such other day as may be determined at the discretion of Assupol Life, or my employer. This authorisation will continue until the termination of the policy or until cancelled by me in writing. I agree and understand that the following conditions apply: 1. This authorisation may be cancelled by me with one calendar months written notice to Assupol Life or my employer. 2. The premium authorised may be escalated by the chosen inflation linked percentage as selected by myself on the proposal form. 3. Should the relevant premium be adjusted by Assupol Life as a result of a contractual (annual) increase in premium, I hereby grant permission that the adjusted premium may be deducted from my salary until such time as I cancel this authorisation in writing or until I substitute it with a new authorisation. I hereby confirm that I have read the information above and understand the content thereof.

Signature of premium payer

Date

Alterations to method of payment

Only applicable for persol deductions I hereby authorise the method of payment to be altered in the event of me not qualifying for persol deduction as follows I hereby confirm that I have read the information above and understand the content thereof. Other stop order Debit order

Signature of premium payer

Date

Banking details (debit order)

Name of bank Account number Preferred date of deduction Branch Type of account Current Branch code Savings Transmission

Premium deduction authorisation

I, the premium payer, hereby instruct and authorise Assupol Life, to draw against my bank account, as indicated above, the premiums in respect of the insurance applied for. I would like the day of deduction as indicated to be used, or such other day as may be determined at the discretion of Assupol Life. This authorisation will continue until the termination of the policy or until cancelled by me in writing. I agree and understand that the following conditions apply: 1. This authorisation may be cancelled by me with one calendar month's written notice to Assupol Life. 2. The premium authorised may be escalated by the chosen inflation linked percentage as selected by myself on the proposal form. 3. Should the relevant premium be adjusted by Assupol Life as a result of a general decrease / increase in subscription or should I request Assupol Life to decrease / increase the subscription for certain reasons, I hereby grant permission that the adjusted premium may be deducted from my bank, until such time as I cancel this authorisation in writing or until I substitute it with a new authorisation. I hereby confirm that I have read the information above and understand the content thereof.

Signature of premium payer

Date

Declaration in respect of long-term insurance products

I hereby apply for the DG family funeral plan in accordance with the conditions and exclusions of the plan as set out in the quotation and policy document. I understand that a policy certificate , including my personal details, chosen benefits and claims procedures (as intended in Section 48 of the Long-term Insurance Act), will be posted to me. In accordance with Long-term Insurance Act, you have 30 days from receipt of the policy certificate to cancel this policy. If this policy is cancelled within 30 days, any payment that has been received will be refunded. I am aware of the waiting periods applicable on this policy. There is a limit of one policy per member under the DG family funeral plan. I, the undersigned, hereby declare and warrant that all information supplied herein, is true and complete. I am aware and understand that any non-disclosure or misrepresentation of information which is material to the determination of the risk by Assupol Life, may lead to the policy being declared null and void, in which case all premiums paid, will be forfeited. I am certain that the product which I am applying for, meets my needs and feel that I have all the necessary information in order to make an informed decision in respect of the purchase thereof. The long-term benefits under this policy are subject to the provisions as set out in the master policy. The long-term policy shall come into force and effect on the inception date provided that the offer for insurance made by the member by way of the proposal form, is unconditionally accepted by Assupol Life and the first premium payable in terms of the policy was received by Assupol Life. I hereby agree that I may be contacted with regard to further marketing, advertising and other lifestyle products.

Signature of premium payer

Date

Declaration by representative
Surname Initials ID number

I hereby declare and warrant that no money has been or will be paid or advanced to any insured life on this policy by me or any other party as an inducement to effect this insurance and that no other consideration has been offered to any insured life. I further declare that no insured life on this policy has in any way been misled by me or as far as I am aware by any other party with regard to the terms and conditions of the policy applied for. I further declare that I have explained the meaning and implications of replacement of an insurance policy to the policy owner and that I am fully aware of the possible detrimental consequences of the replacement of an insurance policy.

Signature of representative

Representative code

Date

Underwritten by

Life Limited

Head office 308 Brooks street, Menlo Park, Pretoria, 0081 Assupol Life Limited reg no 2010/025083/06 An authorised financial services & credit provider