CREDIT LIFE | OVER DRAFT

APPLICATION FORM
(Maximum Insured amount not to exceed N$ 500 000)

Account/Policy Number

Contract Number

1. APPLICANT’S DETAILS

CIF Number Title Gender Male Female

Surname

Maiden Name

First Name(s)

Initial(s) ID/Passport Date of Birth d d m m y y

Tel (w) Cell Tel (h)

Email Address

Postal Address Line 1

Line 2

Suburb

Town

Employer

Occupation

Source of Funds (how will premium be paid)

2. MEDICAL DECLARATION

I, (full name)

by completing this Application Form confirm my intention to enter into a long term insurance relationship with NedNamibia Life Assurance Company Limited whereby I will become
entitled to the following benefits in the event of any claim under the Credit Life Policy hereby applied for: (1) Death; or (2) Permanent Disability in the form of a Lump Sum Benefit.

I furthermore understand, agree and where applicable, declare as follows:

1. Apart from minor ailments, I have not received any treatment from any doctor during the past 12 months or been hospitalised or undergone hospital treatment or special
investigation during the past 5 years and have never suffered from any form of disability or heart attack or heart disease, stroke, cancer, kidney disease or impaired vision, or
AIDS or any AIDS-related condition.
2. At date of application, I am:

Healthy (not receiving any medical treatment nor on chronic medication to address any medical condition highlight in Point 1 above)

Healthy but receiving Medical Treatment

Healthy but on chronic medication

Not sure

If you have answered in the affirmative for either of the question mentioned above apart from indicating yourself as being healthy, please provide full details of your medical
condition including the names of doctors, and/or hospitals, duration of treatment and tests and extent of recovery.

Page 1 of 2
3. NATURE OF COVER

AGE GROUP PREMIUM CALCULATOR* TICK BOX

18 – 35 N$ 9.744 / N$1,000 per annum

36 – 40 N$ 11.832 / N$ 1,000 per annum

41 – 45 N$ 12.168 / N$1,000 per annum

46 – 50 N$ 12.504 / N$1,000 per annum

51 – 55 N$ 12.840 / N$1,000 per annum

56 – 60 N$ 17.784 / N$1,000 per annum

61 - 64 N$ 21.732 / N$1,000 per annum

Outstanding Loan Amount as at date of Application N$ Annual Premium (12 months) N$

4. TERMS AND CONDITIONS

1. All information supplied by me in this application form, whether in my handwriting or not, is true and correct, and forms the basis of my application to be covered under the
policy entered into with NedNamibia Life Assurance Company Limited.
2. Any doctor, person or institution is authorised before or after my death, to provide and assist NedNamibia Life Assurance Company Limited with all information required from
time to time to assess the risk or consider a claim against NedNamibia Life Assurance Company Limited.
3. I understand and accept that Nedbank Namibia Limited (‘the Bank’) is the beneficiary under the policy and that all proceeds will be disbursed to the Bank in the event of any claim.
4. I understand the sum assured under the policy;
a) Will decrease to cover only the outstanding amount of the overdraft as may be due and owing at claim stage; and
b) May be automatically renewed for a further 12 months as long as the overdraft facility is in place.
5. I hereby authorise the Bank to collect and pay the Credit Life Premium as calculated herein to NedNamibia Life Assurance Company Limited and acknowledge that the
premium so paid includes a commission fee of 20%.
6. I am aware that NedNamibia Life Assurance Company Limited will not acknowledge a claim arising directly or indirectly from any condition or any event;
a) Which I misrepresent or concealed; or
b) If the risk was declined by NedNamibia Life Assurance Company Limited; or
c) As reflected in the Summary of Insurance Cover.
7. I hereby agree that, if the application is approved, such approval will occur on condition that;
a) in the sole discretion of NedNamibia Life Assurance Company Limited as to materiality, there has been no change to the facts on which the decision of approval was based
and,
b) I have not suffered from any sickness or sustained any injury from the date on which this application was signed to the commencement date of of the policy.
8. My application for cover under the policy has been made voluntarily and is deemed a reasonable condition for the granting of credit by the institution; and I have been offered
a free choice in effecting an alternative policy with another insurer and through another intermediary, and I have been given the opportunity to cede an existing unencumbered
policy to the institution to cover my debt to them.
9. I acknowledge that it has been explained to me that should I wish to terminate this policy during its tenure, that the pro-rata premium which has been paid by me will be
surrendered by NedNamibia Life Assurance Company Limited and refunded to myself or the Bank, depending on the manner in which the premium was financed. I furthermore
acknowledge that NedNamibia Life Assurance Company Limited shall under no circumstances refund premiums to myself if the said premiums were financed by the Bank. In
such instance, the premiums shall be refunded to the Bank for credit against the outstanding loan amount.
10. I declare that I have the required legal contractual capacity to enter into contracts, and that I read, understood and accepted all of the above and the implications thereof.

Surname

First Name(s)

Signed at on d d m m y y

Preferred means of receiving correspondence from Nednamibia Life Assurance Company?

Email Postal Service
Note: For purpose hereof, the details as provided in Part 1 herein will be use.

5. CONSULTANT DETAILS (Mandatory)

Note: Failure to complete this section in detail would entitle NedNamibia Life Assurance Company Limited to retain any commission to which the Consultant shall be entitled.

Surname

First Name(s) Staff C C

Namfisa Registered Yes No If, ‘Yes’, Namfisa License Number

Signed at on d d m m y y

If NOT REGISTERED, application to be countersigned by registered Namfisa agent

Counter-signed at on d d m m y y
(Registered)

6. FOR OFFICIAL USE – TO BE COMPLETED BY NEDBANK

1. Facility approval date 3. Maturity/Review date

2. Interest rate 4. Date Credit Life premium paid to

(eg 11.50 and not Prime + 4%) NedNamibia Life (Account: 11000370020)

Page 2 of 2