MEDI-AID.HELP FUNERAL & PERSONAL ACCIDENTAL PLAN Step 1 of 6 – PERSONAL DETAILS 16% FacebookThis field is for validation purposes and should be left unchanged.Member Details Member must be between the ages of 18 – 79This field is hidden when viewing the formBroker Information (optional)Bennie Botha (PTA50001)Dean Stopforth (KZN111)Nkosinathi Gumede (KZN009)Samson Hlomuka (PTA10016)Tebogo Josephine LegodiTersius Schutte (BB0023)Leave blank if there is no broker assistance This field is hidden when viewing the formBroker Code (optional)Prefix Mr.Mrs.Ms.Dr.Prof.Rev. Prefix Full Name* First Last ID Number*Date of Birth*Please upload your IDAccepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 32 MB. Marital Status*SingleMarriedDivorcedWidowedGender*MaleFemaleCell Number*WhatsApp NumberEmail Enter Email Confirm Email Physical Address* DependentsFuneral Plan benefits Personal Accidental Plan benefits Please select cover for you as a SINGLE MEMBER or select FAMILY COVER for you and other family members.This field is hidden when viewing the formPlan Option* Single Member Family Cover Main Member’s entry age must be below 69 yearsThis field is hidden when viewing the formSingle Member* OPTION 1: R 80 p/m OPTION 2: R 95 p/m OPTION 3: R 110 p/m OPTION 4: R 120 p/m OPTION 5: R 130 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. This field is hidden when viewing the formFamily 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. NOTE: You may add your spouse/life-partner and/or up to five of your children (maximum of 5 people). None of these are compulsory. The total cost of this plan is R99 pm. Spouse/Life-partnerSpouseFull NameIdentification/Date of BirthID No. OR Date of BirthGenderGenderChild 1Child 1Full NameIdentification/Date of BirthID No. OR Date of BirthGenderGenderChild 2Child 2Full NameIdentification/Date of BirthID No. OR Date of BirthGenderGenderChild 3Child 3Full NameIdentification/Date of BirthID No. OR Date of BirthGenderGenderChild 4Child 4Full NameIdentification/Date of BirthID No. OR Date of BirthGenderGenderChild 5Child 5Full NameIdentification/Date of BirthID No. OR Date of BirthGenderGender 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 1This field is hidden when viewing the formSurname & InitialsSurname & InitialsThis field is hidden when viewing the formID or DoBID No. OR Date of BirthThis field is hidden when viewing the formSpouseRelationshipThis field is hidden when viewing the formCover 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 2This field is hidden when viewing the formSurname & InitialsSurname & InitialsThis field is hidden when viewing the formID or DoBID No. OR Date of BirthThis field is hidden when viewing the formSpouseRelationshipThis field is hidden when viewing the formCover 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 3This field is hidden when viewing the formSurname & InitialsSurname & InitialsThis field is hidden when viewing the formID or DoBID No. OR Date of BirthThis field is hidden when viewing the formSpouseRelationshipThis field is hidden when viewing the formCover 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 1This field is hidden when viewing the formSurname & InitialsSurname & InitialsThis field is hidden when viewing the formID or DoBID No. OR Date of BirthThis field is hidden when viewing the formSpouseRelationshipThis field is hidden when viewing the formCover 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 2This field is hidden when viewing the formSurname & InitialsSurname & InitialsThis field is hidden when viewing the formID or DoBID No. OR Date of BirthThis field is hidden when viewing the formSpouseRelationshipThis field is hidden when viewing the formCover 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 1This field is hidden when viewing the formSurname & InitialsSurname & InitialsThis field is hidden when viewing the formID or DoBID No. OR Date of BirthThis field is hidden when viewing the formSpouseRelationshipThis field is hidden when viewing the formCover 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 2This field is hidden when viewing the formSurname & InitialsSurname & InitialsThis field is hidden when viewing the formID or DoBID No. OR Date of BirthThis field is hidden when viewing the formSpouseRelationshipThis field is hidden when viewing the formRelationshipParentsParents in lawAuntBrotherCousinGrandparentsGrandparents in lawHalf brotherHalf sisterNephewNieceSisterStep brotherStep sisterUncleThis field is hidden when viewing the formCover 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 This field is hidden when viewing the formTotal Cost of Cover Household Dependents NOTE: You may add anyone else that stays with you. This can include your domestic worker, gardener, grandparent or anyone outside of your spouse and/or children (maximum of 3 people). The three people you add are only covered for the Ambulance Emergency Services. Dependent 1Name & SurnameName & SurnameIDID No.RelationshipRelationshipDependent 2Name & SurnameName & SurnameIDID No.RelationshipRelationshipDependent 3Name & SurnameName & SurnameIDID No.RelationshipRelationship 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 Date of BirthContact Number*Contact NumberBeneficiary (optional)This field is hidden when viewing the formBeneficiaryFull NameThis field is hidden when viewing the formID or DoBID No. OR Date of BirthThis field is hidden when viewing the formContact NumberContact Number 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 ActThis field is hidden when viewing the formStatutory 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.