Policy Membership Application - Ledwaba Funeral Parlour

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Ledwaba Friendly Society Membership Form

1. Plan Selection

Family Plan - R150/mo

Main member + 11 beneficiaries. Coffin code 620/s (Service benefit R10,000).

Family Plan - R300/mo

Main member + 11 beneficiaries. Coffin code 620 (Service benefit R20,000).

Stokvel/Group Plan - R150/mo

10+ participants. Main member + 9 beneficiaries per family. Coffin 620/s (Benefit R10,000).

Stokvel/Group Plan - R300/mo

10+ participants. Main member + 9 beneficiaries per family. Coffin 620 (Benefit R20,000).

FSP / Existing Policy Code (If applicable) Leave blank for a new application.

2. Main Member Details

First Name *

Surname *

ID Number *

Street Address *

Suburb / Township *

City / Town *

Postal Code *

Cell Number *

Telephone (Home/Work)

Fax Number

Email Address *

3. Beneficiaries & Dependants

List your family members or beneficiaries to be covered under this policy as per plan limits:

First Name	Last Name	ID Number	Relationship / Status	Action

4. Declaration

I hereby declare that all details provided are true and correct. I accept the Rules and Conditions of Membership and Benefits and agree to pay the monthly premiums on or before the 7th of each month.

Policy Application Form

Ledwaba Friendly Society Membership Form

Family Plan - R150/mo

Family Plan - R300/mo

Stokvel/Group Plan - R150/mo

Stokvel/Group Plan - R300/mo

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