About this form This is your application form for funeral cover on the Master Policy held by Morena’s Style Funeral Service (Pty) Ltd. Please fill in all the relevant sections truthfully and in full using a black pen and make sure your answers are clear and readable. You must provide Mareana Style Funeral Service (Pty) Ltd with your identity document or driver’s licence and those of all the dependants you would like to add to your membership when you apply for cover.
Section A: Your personal details
Section B: What plan would you like to apply for (see your brochure for more details about the plans)?
Section C: Your dependants’ details
Please see your brochure for details on the number of dependants you can add. We require proof of registration from the relevant school, college, university or other academic institution for dependent children who are 21 or older and full-time students.
Section D: Your additional extended dependants’ details
You can add additional dependants to your cover. Additional extended dependants can be your biological parents, biological siblings, spouse, aunt, uncle, parents-in-law, sister-in-law, brother-in-law, step parents or grandparents. You can also add your spouse’s biological siblings
Premiums including your dependants’ premiums
Section E: How would you like to pay for your funeral cover (tick the relevant option)?
Please fill in the relevant section below Stop order (persal code: 0321)
Should the premium be adjusted by BrightRock Life Limited as a result of general increase or decrease in rate or should I request the insurer to increase or decrease my premium for certain reasons, once the form is uploaded our office will call you, to explain the activation process and payment method.
Debit order (Please complete your debit order instruction below)
Section F: Policy owner declaration and signature
By signing this form, you understand and agree that you are applying for funeral cover on the Master Policy held with BrightRock Life Limited. Your policy is administered by Mareana Style Funeral Service (Pty) Ltd and BrightRock Life Limited. You declare that the information you’ve provided in this form is accurate and true and that BrightRock has the right to cancel this policy with immediate effect should they find out any of the information you’ve provided is untrue. You also understand that you will forfeit any premiums paid to BrightRock Life Limited should you provide false information. You declare that your representative has explained the terms and conditions of your cover and you understand them. BrightRock has the right to decline your application within 31 days of the application. If you don’t receive formal communication that your application has been denied within 31 days, you may consider your membership active and binding. Your cover will only start once BrightRock receives your first premium. BrightRock reserves the right to decline your application within 31 days of you applying for cover. If you cancel your policy within 31 days of BrightRock confirming your policy number and policy start date BrightRock will refund your premium (excluding administration fee).
BrightRock Life Ltd is an authorised financial services provider and registered insurer. Company registration no: 1996/014618/06, FSP 11643. Terms and conditions apply. Copyright © January 2019 BrightRock. All rights reserved. Version 2.0. Document reference number: 30000010006