Single Step 1 of 7 14% PLAN TYPE Select your plan type from the options belowSelect Plan Single Plan Family Plan *Required Fields Covers the policy holder(Required) R20k R25k R30k R35k Selected Plan R20k Cover Amount R200 000 Total Premium p/m R100 Selected Plan R25k Cover Amount R25 000 Total Premium p/m R130 Selected Plan R30k Cover Amount R30 000 Total Premium p/m R160 Selected Plan R35k Cover Amount R35 000 Total Premium p/m R200 *Required Fields Covers the policy holder, 1 spouse and up to 5 children(Required) 20k 25k 30k 35k Selected Plan R20k Cover Amount R20 000 Total Premium p/m R140 Selected Plan R25k Cover Amount R25 000 Total Premium p/m R160 Selected Plan R30k Cover Amount R30 000 Total Premium p/m R200 Selected Plan R35k Cover Amount R35 000 Total Premium p/m R250 MAIN APPLICANT Information about the main applicant for the funeral plan*Required Fields Title(Required)MrMrsMsDrProfFull Names(Required) Surname(Required) ID Number(Required)Passport Number Gender(Required)MaleFemaleCellphone Number(Required)Email(Required) Marital Status(Required)SINGLEMARRIEDWIDOWEDDIVORCEDSEPARATEDPostal Address(Required) Suburb(Required) Province(Required)EASTERN CAPEFREE STATEGAUTENGKWAZULU-NATALLIMPOPOMPUMALANGANORTHERN CAPENORTH WESTWESTERN CAPEPostal Code(Required) BENEFICIARY The individual or entity designated to receive the benefits of the plan upon the death of the insured person*Required Fields Untitled First Names*(Required) Surname*(Required) ID Number*(Required)Date of Birth*(Required) MM slash DD slash YYYY Relationship*(Required)SpouseHusbandSisterNephewParentEstateChildWifeBrotherNieceGrandchildExtendedDaughterGuardianFatherAuntGrandmotherEmployerSonLife PartnerMotherUncleGrandfatherCourt AppointeeDivorced SpouseCommon Law SpousePercentage*(Required)10%20%30%40%50%60%70%80%90%100%Cellphone Number*(Required) SPOUSE Covers 1 spouse One person to whom the Main Member is married in terms of law*Required Fields First Names Surname ID NumberDate of Birth MM slash DD slash YYYY CHILDREN Covers up to 5 children *Required Fields Untitled First Names Surname ID NumberDate of Birth MM slash DD slash YYYY PAYMENT METHOD *Required Fields Payment(Required) Pay@ Debit Order Name of Bank(Required)ABN AMRO BANKABSA BANKACCESS BANKAFRICAN BANKAFRICAN BANKING CORP.OF ZIMBABWE LTDAGRICULTURAL BANK OF ZIMBABWE LTDAL BARAKABANK OF ATHENSBANK WINDHOEK BEPERKBANK ZEROBARCLAYS BANK OF ZIMBABWEBARCLAYS BANK PLC SA BRANCHBIDVEST BANKCAPITEC BANKCAPITEC BUSINESS BANKCENTRAL AFRICA BUILDING SOCIETYCITIBANKCOMMERCIAL BANK OF ZIMBABWEDISCOVERY BANK LTDECOBANK ZIMBABWE LIMITEDFBC BANK LTDFBC FIDELITY BANK LTDFINBONDFIRST NATIONAL BANKGENESIS INVESTMENTGRINDRODHABIB OVERSEAS BANK LIMITEDHBZ BANK LIMITEDINTERFINBANKINVESTEC BANKITHALA BANKKINGDOM MERCHANT BANK LIMITEDLESOTHO BANK LTDMEEG BANKMERCHANT BANK OF CENTRAL AFRICA LTDMETROPOLITAN BANK OF ZIMBABWE LTDNATIONAL DISCOUNT HOUSE LIMITEDNEDBANKNMB BANK LIMITEDOLD MUTUAL BANKPEOPLE’S OWN SAVINGS BANKPEOPLES BANK LTD INC. PEP BANKPEOPLES BANK LTD. INCORP. NBSPERMANENT BANKPOST BANKRENAISSANCE MERCHANT BANK LTDRMBRMB PRIVATEROYAL BANK ZIMBABWE LIMITEDS.A. BANK OF ATHENS LTDS.A. RESERVE BANKSTANBIC BANK ZIMBABWE LIMITEDSTANDARD BANKSTANDARD CHARTERED BANK SASTANDARD CHARTERED BANK ZIMBABWE LIMITEDSUREBANKSWAZIBANKSWAZILAND BUILDING SOCIETYSWAZILAND DEVELOPMENT AND SAVINGS BANKTEBA BANKTETRAD SECURITIES LIMITEDTN BANK LIMITED HARARETRUST BANK CORPORATION LIMITEDTYMEBANKUBANKUNIBANK LIMITED (SAMOS ONLY)VBS MUTUAL BANKZIMBABWE ALLIED BANKING GROUPZIMBABWE BANKING CORPORATION LTDBranch Code(Required) Account Type(Required)CHEQUESAVINGSTRANSMISSIONAccount Holder(Required) Account Number(Required) Debit Date1ST OF THE MONTH7TH OF THE MONTH15TH OF THE MONTH25TH OF THE MONTHEND OF THE MONTH (LAST DAY)View Debit Order Mandate DEBIT ORDER MANDATE I hereby authorise Phakama Administration Services on behalf of VyroPlus to commence a debit order withdrawal from my account on the 'debit date' selected above, and monthly thereafter for the premium applicable for the cover selected. I understand that the debit order will be run on the date selected. If for any reason it is not honoured, two withdrawal runs will be done the next month. In the event of this second run being dishonoured, the policy will lapse. I understand it is required that this signed document reaches Phakama offices 10 working days prior to the selected deduction date, if not, the deduction will only qualify for the following calendar month's deductions. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the preceding ordinary business day. Should the relevant premium rate be adjusted by the Institution as a result of an inflation related increase in subscription/premium/payment rate, I confirm that the adjusted premium rate may be deducted. I agree that although this Authority and Mandate may be cancelled by me by giving you notice in writing of not less than 20 ordinary working days, such cancellation will not cancel the Agreement. I shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you. I acknowledge and agree that payment instructions issued from this Mandate will be treated as payment instructions issued personally by myself, the account holder. I acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. The User Abbreviated Name as Registered with the Bank will reflect as follows on your bank account: VYROPLUS followed by your policy/membership number. I declare to the best of my knowledge and belief that the particulars given by me herein are true and correct. I am satisfied that the plan chosen by me suits my needs. I am able to afford the monthly contributions of the plan chosen by me. I have read and understood the Summary of the Terms and Conditions. Close I Agree to the Debit Order Mandate *Required Fields I agree that no financial advice was given during the completion of this application I need additional financial advice before you activate my policy Sign Here(Required)Date Signed View Terms & Conditions DEBIT ORDER MANDATE I hereby authorise Phakama Administration Services on behalf of VyroPlus to commence a debit order withdrawal from my account on the 'debit date' selected above, and monthly thereafter for the premium applicable for the cover selected. I understand that the debit order will be run on the date selected. If for any reason it is not honoured, two withdrawal runs will be done the next month. In the event of this second run being dishonoured, the policy will lapse. I understand it is required that this signed document reaches Phakama offices 10 working days prior to the selected deduction date, if not, the deduction will only qualify for the following calendar month's deductions. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the preceding ordinary business day. Should the relevant premium rate be adjusted by the Institution as a result of an inflation related increase in subscription/premium/payment rate, I confirm that the adjusted premium rate may be deducted. I agree that although this Authority and Mandate may be cancelled by me by giving you notice in writing of not less than 20 ordinary working days, such cancellation will not cancel the Agreement. I shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you. I acknowledge and agree that payment instructions issued from this Mandate will be treated as payment instructions issued personally by myself, the account holder. I acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. The User Abbreviated Name as Registered with the Bank will reflect as follows on your bank account: VYROPLUS followed by your policy/membership number. I declare to the best of my knowledge and belief that the particulars given by me herein are true and correct. I am satisfied that the plan chosen by me suits my needs. I am able to afford the monthly contributions of the plan chosen by me. I have read and understood the Summary of the Terms and Conditions. Close I Agree to the Terms & Conditions
