THE HYPA COMPREHENSIVE FAMILY FUNERAL PLAN Step 1 of 5 – PERSONAL DETAILS 20% PERSONAL DETAILSPrefix Mr.Mrs.Ms.Dr.Prof.Rev. Prefix Full Name* First Last Age* ID Number* Please upload your IDAccepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 32 MB.Marital Status*SingleMarriedDivorcedWidowedGender*MaleFemaleContact Number* Email Enter Email Confirm Email Physical Address*How do you wish to receive your policy document?* Cell/Whatsapp Email Please provide Whatsapp number below if different from Cell numberWhtasApp Number (optional) PLAN OPTIONSPlease select an option on FAMILY COVER for you and other family members.Family Cover* OPTION 1: R 100 p/m OPTION 2: R 115 p/m OPTION 3: R 135 p/m OPTION 4: R 145 p/m OPTION 5: R 165 p/m ASSIST Benefits (inclusive in Options 1 – 5 above) Trauma, Assault & HIV Services Repatriation Services Access to discounted funeral services Emergency Medical Service Discounted Food Vouchers Legal Assist Waiting periods: Natural death – 6 calendar months from Entry date or reinstatement date where applicable; Accidental Death – cover is immediate, subject to 1st month’s premium being received prior to death; Suicide – 12 calendar months from Entry date or reinstatement date where applicable. Dependent DetailsNOTE: You may add your spouse/life-partner and/or up to five of your children. None of these are compulsory, but for Family Cover you MUST add some dependent(s).Spouse/Life-partnerSpouse Full NameIdentification/Date of Birth ID No. OR Date of BirthGender GenderChild 1Child 1 Full NameIdentification/Date of Birth ID No. OR Date of BirthGender GenderChild 2Child 2 Full NameIdentification/Date of Birth ID No. OR Date of BirthGender GenderChild 3Child 3 Full NameIdentification/Date of Birth ID No. OR Date of BirthGender GenderChild 4Child 4 Full NameIdentification/Date of Birth ID No. OR Date of BirthGender GenderChild 5Child 5 Full NameIdentification/Date of Birth ID No. OR Date of BirthGender Gender Extended Family Benefit You can select cover for extended family members. These members are STRICTLY any of the following: Aunt, Brother, Cousin, Grandparents, Grandparents in law, Half brother, Half sister, Nephew, Niece, Parents, Parents in law, Sister, Step brother, Step sister, Uncle. You can only add 3 members in A, 2 members in B and 2 members in C. Please see options below:Waiting periods: Natural death – 6 calendar months from Entry date or reinstatement date where applicable; Accidental Death – cover is immediate, subject to 1st month’s premium being received prior to death; Suicide – 12 calendar months from Entry date or reinstatement date where applicable. A. Extended Family Benefit (0 – 65 years) (optional)Member 1Surname & Initials Surname & InitialsID or DoB ID No. OR Date of BirthSpouse RelationshipCover OPTION 1: R 27 p/m OPTION 2: R 49 p/m OPTION 3: R 71 p/m OPTION 4: R 93 p/m OPTION 5: R 115 p/m You may add another member. This is optionalMember 2Surname & Initials Surname & InitialsID or DoB ID No. OR Date of BirthSpouse RelationshipCover OPTION 1: R 27 p/m OPTION 2: R 49 p/m OPTION 3: R 71 p/m OPTION 4: R 93 p/m OPTION 5: R 115 p/m You may add another member. This is optionalMember 3Surname & Initials Surname & InitialsID or DoB ID No. OR Date of BirthSpouse RelationshipCover OPTION 1: R 27 p/m OPTION 2: R 49 p/m OPTION 3: R 71 p/m OPTION 4: R 93 p/m OPTION 5: R 115 p/m B. Extended Family Benefit (66 – 75 years) (optional)Member 1Surname & Initials Surname & InitialsID or DoB ID No. OR Date of BirthSpouse RelationshipCover OPTION 1: R 41 p/m OPTION 2: R 77 p/m OPTION 3: R 113 p/m OPTION 4: R 147 p/m OPTION 5: R 185 p/m You may add another member. This is optionalMember 2Surname & Initials Surname & InitialsID or DoB ID No. OR Date of BirthSpouse RelationshipCover OPTION 1: R 41 p/m OPTION 2: R 77 p/m OPTION 3: R 113 p/m OPTION 4: R 147 p/m OPTION 5: R 185 p/m C. Extended Family Benefit (76 – 85 years) (optional)Member 1Surname & Initials Surname & InitialsID or DoB ID No. OR Date of BirthSpouse RelationshipCover OPTION 1: R 55 p/m OPTION 2: R 105 p/m OPTION 3: R 155 p/m OPTION 4: R 205 p/m OPTION 5: R 255 p/m You may add another member. This is optionalMember 2Surname & Initials Surname & InitialsID or DoB ID No. OR Date of BirthSpouse RelationshipCover OPTION 1: R 55 p/m OPTION 2: R 105 p/m OPTION 3: R 155 p/m OPTION 4: R 205 p/m OPTION 5: R 255 p/m Total Cost of Cover NOMINATED BENEFICIARY(if the Main Member passes way)The beneficiary has to be any natural person over the age of 18. The beneficiary will receive 100% benefit. You have the option to add a second beneficiary, should the first beneficiary be deceased/incapacitated due to unforeseen circumstances. The second beneficiary will also receive 100% benefit.Beneficiary *Beneficiary* Full NameID or DoB* ID No. OR Passport No. OR Date of BirthContact Number* Contact NumberRelationshipParentsParents in lawAuntBrotherCousinGrandparentsGrandparents in lawHalf brotherHalf sisterNephewNieceSisterStep brotherStep sisterUncleSpousePartnerRelationshipBeneficiary (optional)Beneficiary Full NameID or DoB ID No. OR Date of BirthContact Number Contact NumberRelationshipParentsParents in lawAuntBrotherCousinGrandparentsGrandparents in lawHalf brotherHalf sisterNephewNieceSisterStep brotherStep sisterUncleSpousePartnerRelationship ACCEPTANCE OF TERMSVerification* I hereby consent and authorise Infussion Financial Services to verify my and my beneficiaries ID particulars from the Department of Home Affairs.Communication* I furthermore grant Infussion Financial Services & Infussion Brokers permission to communicate with me through WhatsApp and various communication channels in order to send me other applicable Product information.Terms and Conditions* I have read, understand and accept the Terms and ConditionsPOPIA* I have read, understand and accept the POPI ActStatutory Notice* I have read, understand and accept the Statutory Notice DEBIT ORDER INFORMATIONAccount Holder Name* Bank*Please SelectAbsa BankAccessAfrican Bank LimitedBank ZeroBidvest Bank LimitedCapitec Bank LimitedDiscoveryFirst National BankInvestec Bank LimitedNedbank LimitedSouth African PostbankSpotStandard Bank of South AfricaTyme BankAccount Number* Account Type*Please SelectCurrent / Cheque AccountSavings AccountTransmission AccounntBranch Code* Preferred Debit Order Date*1st15th25thDebit Order Mandate* I hereby consent and authorise Infussion Financial Services to perform a Debit Order Mandate.PLEASE NOTE: Once you click on Submit you will be redirected to sign by using your mouse or finger.CommentsThis field is for validation purposes and should be left unchanged.