Application Form

Applicant information
Application name (if different to principle member)
Personal Details of Principle Member(oldest spouse if family plan)
Title
Full Name
Surname
Gender
ID no
Tel {H}
Tel {W}
Tel {Cell}
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Marital Status
Email Address
Address
Postal Address Physical Address ZIP / Postal Code

Elected Beneficiary 1
Elected Beneficiary 1 (Needs to be older that 18)
ID no
Tel
Title
Relationship
Date of Birth
Date Format: MM slash DD slash YYYY
Elected Beneficiary 2
Elected Beneficiary 2 (Needs to be older that 18)
ID no
Tel
Title
Relationship
Date of Birth
Date Format: MM slash DD slash YYYY
Spouse
Title
Full Name
Surname
Gender
ID no
Tel {H}
Tel {W}
Tel {Cell}
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Address
Postal Address Physical Address
Email Address
Children (max of 6 per policy)/ Dependents
Clarification on Children and Dependents: Children are aged under and covered until 21, covered on a sliding scale of benefits. Cover is extended until 26 on provision of a letter form a registed instuition and confirmation that they are single. dependents are adults, charged seperately but covered under the policy. UNDER THE MULTIPLE FAMILY PLANS THERE ARE NO SPOUSES OR CHILDREN ALL INDIVIDUALS ON THE POLICY ARE DEPENDENTS. PLEASE ENTER CHILDREN FIRST ONTO APPLICATION FORM AND THEN THE EXTENDED MEMBERS IF APPLICABLE.
Name
Surname
Identity Number
Date of Birth
Date Format: MM slash DD slash YYYY
Incep Age
Extended
Relationship to Main Member
Children/ Dependents 2
Name
Surname
Identity Number
Date of Birth
Date Format: MM slash DD slash YYYY
Incep Age
Extended
Relationship to Main Member
Children/ Dependents 3
Name
Surname
Identity Number
Date of Birth
Date Format: MM slash DD slash YYYY
Incep Age
Extended
Relationship to Main Member
Children/ Dependents 4
Name
Surname
Identity Number
Date of Birth
Date Format: MM slash DD slash YYYY
Incep Age
Extended
Relationship to Main Member
Children/ Dependents 5
Name
Surname
Identity Number
Date of Birth
Date Format: MM slash DD slash YYYY
Incep Age
Extended
Relationship to Main Member
Children/ Dependents 6
Name
Surname
Identity Number
Date of Birth
Date Format: MM slash DD slash YYYY
Incep Age
Extended
Relationship to Main Member

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Accept Terms*
I, the applicant, hereby declare and warrant any and all information supplied in my application, to be true and correct. I am aware and understand that any non-disclosure and/or misrepresentation of information which is used to determine risk by the underwriter may lead to any claims being repudiated. I am convinced that the product for which I am applying is suitable to my requirements and have been adequately informed by Oakleigh Life.
Identity Number of Applicant
Postal Address of Applicant
Street Address Address Line 2 City ZIP / Postal Code
Contact Number Cell
Relationship to Main Insured
Total
R0.00
Includes joining fee

Step 1 of 4

SASSA

Single

2 Spouses

Flexi

Single

2 Spouses

6 Individuals (Spouses & Other)

10 Individuals (Spouses & Other)

Service Plan sassa

Service Plan sassa

Service Plan sassa

Service Plan sassa 2 spouses

Service Plan sassa

Service Plan sassa

Service Plan flexi

Tombstone

Tombstone

Catering

Catering

Household

Household

6 and 10

6 and 10

Standard

Single cash plan

Single cash plan

Single cash plan

Single with children cash plan

Single with children cash plan

Single with children cash plan

Family

Family

Family

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18-64

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65-69

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70-74

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Tombstone single

Tombstone single with children

Tombstone family

Catering single

Catering single with children

Catering Family

Household single

Household single with children

Household Family

Applicant information

Personal Details of Principle Member(oldest spouse if family plan)

Elected Beneficiary 1

Elected Beneficiary 2

Spouse

Children (max of 6 per policy)/ Dependents

Children/ Dependents 2

Children/ Dependents 3

Children/ Dependents 4

Children/ Dependents 5

Children/ Dependents 6

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