Join Us - Seetsa Finance

Name:

Surname:

ID Number:

Cell Number:

Email Address:

Physical Address:

Policy Number:

Commencement Date:

Benefit Amount:

Premium:

Plan Selected

Individual

Family Cover

Family Cover (6 Members)

Family Cover (10 Members)

Stockvel & Societies

Grocery Benefit

Spouse's Details

Name:

Surname:

ID Number:

Contact Number:

Email Address:

Additional Members

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Initials & Surname:

ID Number:

Relation:

Benefit:

Declaration

I declare to the best of my knowledge and understanding that the particulars on the certificate are true and correct. I confirm the following by ticking each block.

I can afford the policy monthly premium.

This funeral policy suits my financial needs and expectations and I will read the terms and conditions contained hereof.

The master policy provides additional information on your policy and is available at the office of your appointed intermediary or can be requested from BrightRock. You confirm that BrightRock may validate the information requested and provided where required;
The funeral benefit that BrightRock Limited pays will be in rand value. I nominate the following person to receive the benefit:

Beneficiary:

Contact Details:

Signature:

Upload Signature:

Date:

By signing and submitting this form, you understand and agree that you read the terms and conditions and are applying for funeral cover with BrightRock Life Limited. Your policy is administered by Executive Underwriting Managers CC. You declare that the information you have provided in this form is accurate and true and that BrightRock Life Limited has the right to cancel this policy with immediate effect should they find out any of the information you 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. You confirm that BrightRock may validate the information they request and that you’ve provided, where required.

By signing and submitting this application form, you agree that you appoint Seetsa Finance (Pty) Ltd to find favourable insurance cover for you from time to time. You agree that they can act on your behalf and do whatever is necessary to get you favourable insurance cover. You further nominate Seetsa Finance (Pty) Ltd as your additional contact point for all communication about this policy. You’re satisfied that the plan you’ve chosen best suits your needs and you’re able to afford the monthly funeral insurance premium.

Are you replacing an existing funeral policy with this policy?

Yes No

Application Date:

Membership Start Date:

Main Member Signature:

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Date:

Seetsa Finance Online Application Form

Plan Selected

Spouse's Details

Additional Members