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NewMember Application Form

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MULTIDO (PTY) LTD, registration number 2015/300404/07, is a licensed insurer authorized to conduct life insurance business and a registered financial services provider (FSP 55361). Prior to providing a quote, we require your personal information to assess your risk profile. By signing this application form, you acknowledge acceptance of the contract.

The personal information provided will be used exclusively for the purpose of issuing an insurance policy. In compliance with POPIA, all submitted information will be utilized solely for this stated purpose. This information may be shared with reinsurers to facilitate the provision of this insurance service. Multido (pty) ltd is committed to safeguarding the integrity and confidentiality of personal information in its possession or control by implementing appropriate, reasonable technical and organizational measures to prevent the loss, damage, unauthorized destruction, or unlawful access to or processing of personal information.

We request your consent to process and share your information with authorized third parties, including credit bureaus, to verify details, comply with regulatory requirements, and manage our products and services effectively. Please note that some of our consultants work under supervision.

SECTION A: Personal Details

Broker or Agent

Title

Initials

Gender

First Name

Last Name

Identity / Passport Number

Age

Cell No

Address

Address Line 1

Address Line 2

Town/City

Province

Postal Code

Country

Occupation

Source of Income

Spouse's Details

Title

Initials

Gender

First Name

Last Name

Identity / Passport Number

Age

SECTION B: Benefit Details

Funeral Option

Main Member Funeral

Group Scheme Funeral

Age Group

18-65

66-75

Thank you For Choosing MultiDo Insurance as your preferred Service Provider. Please leave your details below, and we will contact you shortly.

First Name

Last Name

Phone/Mobile

Notes

Main Member Funeral Plan 18-65

Main Member Only

Main Member & Spouse

Main Member & up to 6 Children

Main Member, Spouse & up to 6 Children

Main Member Funeral Plan 66-75

Main Member Only

Main Member & Spouse

Main Member & up to 6 Children

Main Member, Spouse & up to 6 Children

Main Member Only Cover

Main Member & Spouse Cover

Main Member & up to 6 Children Cover

Main Member, Spouse & up to 6 Children Cover

Main Member Only Cover 66-75

Main Member & Spouse Cover 66-75

Main Member & up to 6 Children Cover 66-75

Main Member, Spouse & up to 6 Children Cover 66-75

Extended Family

18-65

66-75

SECTION C: Dependant's Details

NOTE: POPIA requires you to obtain prior consent from persons you would like to cover in this policy.
By granting us your dependents' details, you confirm that you have obtained prior consent from your dependents and or their legal guardians should they be minors.

Extended 18-65 Cover1

Full Names & Surname

Relationship to Insured

Identity Number1

Extended 66-75 Cover1

Full Names & Surname

Relationship to Insured

Identity Number1

Extended 18-65 Cover2

Full Names & Surname

Relationship to Insured

Identity Number2

Extended 18-65 Cover3

Full Names & Surname

Relationship to Insured

Identity Number3

Extended 18-65 Cover4

Full Names & Surname

Relationship to Insured

Identity Number4

Extended 18-65 Cover5

Full Names & Surname

Relationship to Insured

Identity Number5

Extended 18-65 Cover6

Full Names & Surname

Relationship to Insured

Identity Number

SECTION D:Nominated beneficiary’s details.

Please fill in the details of your nominated beneficiary below. The nominated beneficiary is the person you select to receive all the benefits paid out under this policy. You agree that the insurer will not be liable for any claims (from you, your estate, relatives or any other person) related to the payment of these benefits to
your nominated beneficiary

Title

Initials

Gender

Identity Number

First Name

Last Name

Relationship to Policy Holder

Provide Detail about Other

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Source of Income

Provide Detail if Other

Do you declare that all particulars in this quote are true and complete in every respect, that no information has been suppressed or withheld, and that all claims have been fully declared? Do you accept this quote and the premium quoted?

Yes

Signature

Sign Here

Date