CORNERSTONE Tel (012) 685 8300 Fax (012) 685 8315, The Cornerstone Solution Single Funeral Plan - Debit order My name My intermediary My intermediary's telephone numberThe Cornerstone Solution ASSUP@L Single Funeral Plan - main policy Debit-order application form CORNERSTONE Policy number | 21 Please make sure that you understand this entire form, as well asthe policy provisions provided with i. Complete al pages carefully, making sure that all blocks selected are marked clearly with an X, and then sign the form. We will consider your application according to our underwriting rules and practice, Tell us immediately if any information changes. You and we (Assupol) are the only persons involved in entering into this policy. Caen Fulfst Surname Title ) initials Gender {male female 1D ) ( ‘Marital status single married divorced widowed Tel (work) | Cell Tel (home) E-mail ) (eet or postal adress Postal code | MN ee TT Fultst sumame © ( } Relaionshiptoyou [ Analysis of your funeral needs and record of advice Itis important that youhave the right and enough funeral insurance to meet your and your family’sneeds. To achieve this itis necessary to analyze your funeralinsuranceneeds. Your ntermediary must complete thisneeds analysis, What are your needs? Based on your answers, the product will meet your needs because 1. Doyouorthe mainiteinsured have unertcover? [yes Coe 12) 5 vouor the rani nsred wil ave finer cove 2. yes anerthe question below C) 2. Your or the main if insureds existing funeral 2.1 How many funeral policies do you and the main fe insured have? Cover wil increase © 3. Yowor the main ife insured will have additional benefits 4. Other reasons The following was discussed with me: 2.2. How much is your or the main life insurea!s total existing funeral cover? 23, How much is your or the main fe insured’s existing total monthly premium? 3. Doyoucryourmainifeinsured need funeralcoven 1. Waking periods applicable CO 4, Doyou or the main life insured want to insure other lives? —_[ 2. premiums are not paid in full benefits an) ‘Are you or the main life insured taking out this policy to ( no J also cannot be paid in full. > replace oy of your esting Instance poise? 43 Palcyprewsions O == Policyholder - amen oe OPEL ) as L J ‘About your beneficiary ‘This s the person you appoint to claim and receive the policy benefits after your death, He or she must be 18 years or older. You may change your beneficiary at any time for example, if you get married or divorced. ffor any reason payment cannat be made to your beneficiary, we may pay the amount required forthe life insured's funeral tothe undertaker who handles the funeral orto the person who proves that he or she has paid forthe funeral Any maining benefits willbe paid o your deceasedestate Fall first Sumame D ) Title Initials | Gender’ male | female Relationship to you 1 Cormerstone Solution Single debit-order application form soscenbu 209rayrunte| 21 Benefits and premiums you may select ees || rian || cove || Monthy.) | patettttnea || Pam || covr_|] pera, 18-64 years > A 6000 850 65-7Ayears > F i000 || atso 18-64 years > 8 i200 || _ Ras 65-7Ayeare > 6 ais000 || Riso 18-64 years > c 20000 R110 75-79 years mol # 10.000 200 18-64years > D Ras 000 R130 18-64 years > E 30000 R150 Total monthly premium | R Cee cee Iwill pay by debit order. Iwill pay from Account-holder Name of bank Name of branch ‘Account number } Branch code Type of account [ Payment must be made on the current day of every month, savings transmission {authorize Assupol t draw the premiums from my bank account. Ifthe premium changes fr any reason in terms ofthe policy, or by agreement between Ass andthe poicolge the changed premum may hkewse be craw fam my bang accouns. payment cannot be dane onthe prefered day of themanth filed in above; it-must be done on» day that las close a possible to that day, determined by Assupol. the paley ends, ENisauthorization aso ends. Imay cancel, amend or replace this authorization by writen notice to Assupol 1 accept that Assupol must recelve the notice not later than 20 days before the month from which the cancelation, amtendment or replacement isto apply. The relerence on your bank ecountstatementwillstort oth: Assupol My signature Date Petcare I declare thatall information in this formis complete and correct, and that|receiveda signed copy. lamsatisfiedthatl understand everything needto know about the policy and my funeral needs analysis above, and that willbe able to pay the premiums. understand thatif information isnot correct, benefits under the policy may be declined and premiumspaid could beforfeited Companies in the Assupol group of companies may from time to time offer other products or services to me. yes My signature one ("| (Sea eed Initials Surname { Intermediary lL code I have checked that this form hasbeen properly completed and signed. | discussed, and the policy provisions provided witht, withthe policyholder. Ihave not given, and willnot give, money or anything of value tothe policyholder oralifleinsured as an inducement to take outthispplicy-lexplained to the policyholder the implications of replacing insurance. | informed the policyholder that, for services rendered in respect ofthis application and the policy, Assupol paysme an once-off commission equalto between 125% and 200% ofthe first month's premium Province Intermediary’s signature Cate) Sarre eres |Lam responsible for doing a final overall check of this application form. | have checked that it has been completed and signed propery. The Intermediary code used for thisapplication isthe one recorded Inthe disclosure etter signed by the intermediary who assisted withthis appication. Intermediary supervisor signature Date Il } Name of intermediary supervisor 2 Comerstone Solution Single debit-order application formPolicy provisions ‘The Cornerstone Solution - Single Funeral Plan Your policy, and our contractual commitment, takes effect when we (Assupel) accept your application for the policy. Your application form and these policy provisions are the completeandonly record of your policy, and also the summary of your policy. Life insured This s a person whose lifes insured under your policy. This s you, or the main life insured. You must have an insurable interestin the main life insured. You have, for example, such an interest in your spouse, children, parents and other family members Main life insured This s the person whose life you insure under your policy if your life isnot insured under the policy. When cover and waiting periods start For every life insured death cover for an accidental death starts, and the waiting period for death cover for natural (non-accidental) death and. sulcide starts, on the first day of the month in which the first monthly prernium for cover for that life insuredisdue, The waiting period for natural death is six months. For suicide tis 12 months. During a waiting period premiums must be paid, but benefits are not provided ‘Accidental death is death caused by an incident that causes harm to the body of the life insured from outside the life insured, which haem excludes any sickness and which incident and harm the life insured did not intend and reasonably could not have foreseen. The incident must bbe the directand only cause of death, and death must happen within 30 days after theincident. ‘Ageoflifeinsured when cover starts You, and themainlife insured, must be underage 80. ‘Maximum funeral coverforoneperson When a person takes out funeral insurance with us, the total funeral cover for that person under all individual and group policies with us ‘may not be more than the following maximums: REO 000 its taken out when they are 18 years or older, but under age 65; and R25 000 if they are 65 years or older. Any cover above the maximum automatically falls away. Aboutyour premiums The premium for your policy is payable monthly, before the end of every month. The premium we receive in a particular month provides cover for that month. The premium pays for death cover only, and not for any investment or cash value. Premiums arenot refunded ifyourpolicy ends forany reason. Iftwo monthly premiumsin arow are not paid, and both are not paid by the end of the month in which the second premium should have been. paid, your policy ends automaticaly. f your policy has ended because premiums were not paid, you may, within two months, apply foritto be Feinstated subject any policy provisions wemay require, If premiums arenot paidin full, benefits also cannot be paidin ull. Only a percentage of the benefit can then be paid namely apercentage that Is the same as the percentage of premiums paid. For example, ifyou had to pay premiums of R1 000, but paid only R500, it means you paid only '50%6of the premiums. Therefore, only 50% of the benefitscan then be paid. So, ifthe benefitamountisR10000, only RS 000can be paid, When policy benefits willnotbepaid benefit will not be paid if information (for example, about your relationship with ives insured or the age oflives insured}, was not provided to sbeforethe start of the benefit in question, orisnot correct. benefit wil also not be paid the ifeinsured's death is caused or accelerated directly or indirectly by war, participation in civil commotion or terroristactvity,orif the life insured dies while committing acriminalactivty Youcancancel yourpolicy You can cancel your policy at any time by written notice to us. f we receive your notice within 31 days after you have received these policy provisions, your policy ends when we receive your notice. This is knowns a cooling-off aancellation. fwe receive your natice after the 31 days, your policy will end atthe end of the month in which we receive your notice, and then premiums received after the policy has ended will be refunded, ‘The actuarial basis of your policy Your policy operates according to actuarialrules, specifications and formulae, which are approved according tolaw, and which are known asthe actuarial basi of your policy. This ensures that your policyisfinancially sound, andis carried out properly and fairly.Policy provisions continued ‘The Cornerstone Solution - Single Funeral Plan Information about you We may use information about you, also personalinformation meant inthe Protection of Personal Information Act, that we lawfully obtained inthe pastor may obtainin future, including theinformation provided for your application for this policy, for thefollowing purposes: toconsider applications for insurance of which youare the policyholder oralifeinsuted;and forall purposes of such insurance, isued inthe past orin future, particularly to consider claims for benefitsandtotrace persons who could receive benefits \We may for these purposes, at any time, also after your death: ‘obtain such information from other persons and entities, particularly from other insurers and registered credit bureaus, andyouauthorize ther to ‘lve such information tous; Share such information with other insurers ~ directly or through a data base that insurers operate as a group, and in such form as we or the ‘operatorsofthe database may decide. How to claim a policy benefit Visit any of ourbranches,setoutonttheback of this folder or phone 0861 235664, Our branches arealso open on Saturdays from08:00t0 13:00, \We must receive a completed claim form within six months, afterthe death ofthe lfe insured, The persons who claims must, at their own cost, prove the claim show thatno exclusions apply, and give usallinformationand documents weneedto consider the claim, Thismmustinclude: the claim form completed and signed asrequired certified copy ofthe valid ID document ofthe person who claims Certified copy ofthe orignal death certificate ofthe lfeinsured— form DHAS Certified copy ofthe validID document of thelifeinsured, with deceased’ or a similarnotice stamped onit copy ofthenotification/registration-of death ~formDHA1653 copy of avalid bank statement ofthe person who claims, not olderthan three months, showing the account-holder and the account number police report ifthe death isdue to unnatural causes—forexample,amotor-vehicle accident btherdocuments that we may reasonably require, Forotherassistance Visit any of our branches, or contact our client services department: tel 0861 235664 . e-mail clentservicestassupolcoza . fax 0861329287 . post PO Box 35900, Menlo Park, Pretoria, 0102 Complaints Our commitment isto provide excellent service to you. If after having contacted one of our offices or our client-services department, you are still not satisfied, please contact our complaints department tel 0870980290 - e-mail complaints@assupolcoza * fax 0872305569 - pest POBox 35900, Menlo Park, Pretoria, 0102 If after you have contacted our complaints department, you are still not satisfied, you could approach the: (Ombudsman for long-term insurance - about an aspect of your policy || Fais Ombud - about the conduct ofthe intermediary who assisted you| fox 0216740951 tel (012 470 9080 /012 762 5000 Je-mail — infogombudcoza fax 0123483447 post Private Bag X45, Claremont, 7735, e-mail infowfaisombud.coza Post PO Box 74571, Lynnwood Ridge, Pretoria, 0040 Underwritten by Assupol Life Ltd fegno2010025088/06 + Authored acl seriees provide + wasiupacaza + Sunt lace Oe Pak, Bung 221 Gansfonten oad Menln Pearl 018Our branches { wt, can eee oe oo co Sci cons Srovemec ‘sigan ‘snapper 0288 Sah eo ‘bombs pra etch Pan apes Teeny romerae Snesana Care eu Na wngn iy NewnSa58 rooest eer Sete oe eee che