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.

Membership number

Mareana Style branch name

Society name

Start date

DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date

Time

Application date

DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date

Time

Section A: Your personal details

Membership number

Title

Age at start

Group member number

Name *

First

Last

Work number

Cellphone number

Email address *

Address

Address Line 1

City

State / Province / Region

Postal Code

AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia (Republic of)MadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States of AmericaUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweCountry

Section B: What plan would you like to apply for (see your brochure for more details about the plans)?

Single Line Text

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.

Full name and surname I Relationship to main member l National Identification Number

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

Full name and surname I Relationship to main member l National Identification Number

Premiums including your dependants’ premiums

Main member premium

Extended members premium

Catering premium

Total premium

Section E: How would you like to pay for your funeral cover (tick the relevant option)?

Payment method

• Stop order
• Private stop order
• Debit order
• Cash

Please fill in the relevant section below Stop order (persal code: 0321)

Full name of authorised person *

First

Last

Monthly amount

Employer’s name

Pay station

National Identification Number

Your paydayDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Your employee code/salary number

Deduction start dateDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Policy or membership number

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.

Authorised person’s signature:

Clear Signature

DateDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Debit order (Please complete your debit order instruction below)

Name of bank

Account-holder *

First

Last

Account number

Branch name

Branch code

Account type

• Current
• Saving

Preferred debit order day?

Signature of the account holder

Clear Signature

DateDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

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).

Signed at

Signature of main member

Clear Signature

Name of the representative *

First

Last

Signature of the representative

Clear Signature

Name of the FSP

FSP number

Membership start date DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

FSP BrightRock Life Limited contract number

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

Signature of main member

Clear Signature

Date

File Upload

Message

Submit