Thom Kight Funeral Plans Step 1 of 7 14% PLAN TYPE Select your plan type from the options belowSelect Plan Single Plan Family Plan *Required Fields Covers the policyholder(Required) R22k R27k R32k R37k Selected Plan R22K Cover Amount R22 000 Total Premium p/m R150 Selected Plan R27K Cover Amount R27 000 Total Premium p/m R165 Selected Plan R32K Cover Amount R32 000 Total Premium p/m R180 Selected Plan R37K Cover Amount R37 000 Total Premium p/m R200 *Required Fields Covers the policyholder, 1 spouse and up to 6 children(Required) R22K R27K R32K R37K Selected Plan R22K Cover Amount R22 000 Total Premium p/m R250 Selected Plan R27K Cover Amount R27 000 Total Premium p/m R300 Selected Plan R32K Cover Amount R32 000 Total Premium p/m R350 Selected Plan R37K Cover Amount R37 000 Total Premium p/m R400 MAIN APPLICANT Information about the main applicant for the funeral plan*Required Fields Title(Required)MrMrsMsDrProfMain Member First Name(Required)Surname(Required)ID Number(Required)Passport NumberGender(Required)MaleFemaleCellphone Number(Required)Email(Required) Marital Status(Required)SINGLEMARRIEDWIDOWEDDIVORCEDSEPARATEDPostal Address(Required)Suburb(Required)Province(Required)EASTERN CAPEFREE STATEGAUTENGKWAZULU-NATALLIMPOPOMPUMALANGANORTHERN CAPENORTH WESTWESTERN CAPEPostal Code(Required) BENEFICIARY The individual or entity designated to receive the benefits of the plan upon the death of the insured person*Required Fields Beneficiary First Name*(Required)Surname*(Required)ID Number*(Required)Date of Birth*(Required) MM slash DD slash YYYY Relationship*(Required)SpouseHusbandSisterNephewParentEstateChildWifeBrotherNieceGrandchildExtendedDaughterGuardianFatherAuntGrandmotherEmployerSonLife PartnerMotherUncleGrandfatherCourt AppointeeDivorced SpouseCommon Law SpousePercentage*(Required)100%Cellphone Number*(Required) SPOUSE Covers 1 spouse One person to whom the Main Member is married in terms of law*Required Fields Spouse First NameSurnameID NumberDate of Birth MM slash DD slash YYYY CHILDREN Covers up to 5 children *Required Fields Untitled Child First NameSurnameID NumberDate of Birth MM slash DD slash YYYY PAYMENT METHOD *Required Fields Payment(Required) Debit Order Name of Bank(Required)ABN AMRO BANKABSA BANKACCESS BANKAFRICAN BANKAFRICAN BANKING CORP.OF ZIMBABWE LTDAGRICULTURAL BANK OF ZIMBABWE LTDAL BARAKABANK OF ATHENSBANK WINDHOEK BEPERKBANK ZEROBARCLAYS BANK OF ZIMBABWEBARCLAYS BANK PLC SA BRANCHBIDVEST BANKCAPITEC BANKCAPITEC BUSINESS BANKCENTRAL AFRICA BUILDING SOCIETYCITIBANKCOMMERCIAL BANK OF ZIMBABWEDISCOVERY BANK LTDECOBANK ZIMBABWE LIMITEDFBC BANK LTDFBC FIDELITY BANK LTDFINBONDFIRST NATIONAL BANKGENESIS INVESTMENTGRINDRODHABIB OVERSEAS BANK LIMITEDHBZ BANK LIMITEDINTERFINBANKINVESTEC BANKITHALA BANKKINGDOM MERCHANT BANK LIMITEDLESOTHO BANK LTDMEEG BANKMERCHANT BANK OF CENTRAL AFRICA LTDMETROPOLITAN BANK OF ZIMBABWE LTDNATIONAL DISCOUNT HOUSE LIMITEDNEDBANKNMB BANK LIMITEDOLD MUTUAL BANKPEOPLE’S OWN SAVINGS BANKPEOPLES BANK LTD INC. PEP BANKPEOPLES BANK LTD. INCORP. NBSPERMANENT BANKPOST BANKRENAISSANCE MERCHANT BANK LTDRMBRMB PRIVATEROYAL BANK ZIMBABWE LIMITEDS.A. BANK OF ATHENS LTDS.A. RESERVE BANKSTANBIC BANK ZIMBABWE LIMITEDSTANDARD BANKSTANDARD CHARTERED BANK SASTANDARD CHARTERED BANK ZIMBABWE LIMITEDSUREBANKSWAZIBANKSWAZILAND BUILDING SOCIETYSWAZILAND DEVELOPMENT AND SAVINGS BANKTEBA BANKTETRAD SECURITIES LIMITEDTN BANK LIMITED HARARETRUST BANK CORPORATION LIMITEDTYMEBANKUBANKUNIBANK LIMITED (SAMOS ONLY)VBS MUTUAL BANKZIMBABWE ALLIED BANKING GROUPZIMBABWE BANKING CORPORATION LTDBranch Code(Required)Account Type(Required)CHEQUESAVINGSTRANSMISSIONAccount Holder(Required)Account Number(Required)Debit Date1TH OF THE MONTH2TH OF THE MONTH3RD OF THE MONTH4TH OF THE MONTH5TH OF THE MONTH6TH OF THE MONTH7TH OF THE MONTH8TH OF THE MONTH9TH OF THE MONTH10TH OF THE MONTH11TH OF THE MONTH12TH OF THE MONTH14TH OF THE MONTH15TH OF THE MONTH16TH OF THE MONTH17TH OF THE MONTH18TH OF THE MONTH19TH OF THE MONTH20TH OF THE MONTH21ST OF THE MONTH22ND OF THE MONTH23RD OF THE MONTH24TH OF THE MONTH25TH OF THE MONTH26TH OF THE MONTH27TH OF THE MONTH28TH OF THE MONTH29TH OF THE MONTH30TH OF THE MONTHEND OF THE MONTH (LAST DAY)View Debit Order Mandate DEBIT ORDER MANDATE Written Authority and Mandate for Debit Order Instructions: I hereby authorise Phakama Administration Services on behalf of King Price Life Limited for Thom Kight Funeral Plans to commence a debit order withdrawal from my account on the date mentioned above, and monthly thereafter for the premium applicable for the cover selected. I understand that the debit order will be run on the date selected. If for any reason it is not honoured, two withdrawal runs will be done the next month. In the event of this second run being dishonoured, the policy will lapse. I understand it is required that this signed document reaches Phakama offices 10 working days prior to the selected deduction date, if not, the deduction will only qualify for the following calendar month’s deductions. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the preceding ordinary business day. Should the relevant premium rate be adjusted by the Institution as a result of an inflation related increase in subscription/premium/payment rate, I confirm that the adjusted premium rate may be deducted. I agree that although this Authority and Mandate may be cancelled by me by giving you notice in writing of not less than 20 ordinary working days, such cancellation will not cancel the Agreement. I shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you. I acknowledge and agree that payment instructions issued from this Mandate will be treated as payment instructions issued personally by myself, the accountholder. I acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. The User Abbreviated Name as Registered with the Bank will reflect as follows on your bank account: THOMKIGHT followed by your policy / membership number. Close View Popia Consent POPIA Consent I hereby consent to the processing and sharing of my personal information for this application and have obtained consent from all the adult lives assured for their personal information to be so processed and shared. I also declare that I’m legally competent to consent to the personal information of children under 18 being so processed and shared. This consent remains valid even if the policy is cancelled or lapses. I hereby declare that, all the information provided in this form is true and correct and will form the basis of this Policy; I have fully acquainted myself with the plan/product selected which meet my needs and I have been given all the necessary information in order to make an informed decision in respect of the purchase thereof; I understand and accept the Benefits, Terms and Conditions of this Policy; and I understand that a Policy Certificate, including my personal details, chosen Benefits will be sent to me. Close Debit Order I Agree to the Debit Order Mandate POPIA I Agree to POPIA Consent *Required Fields financial advice(Required) I agree that no financial advice was given during the completion of this application Sign Here(Required)Date SignedView Terms & Conditions Terms & Conditions Close Preview × Capture Screenshot Terms & Conditions(Required) I Agree to the Terms & Conditions Δ
