I, the applicant, declare that according to my knowledge the above information is correct and that I am obliged to abide by the terms and conditions summarized in the scheme information, I understand that failure to pay premiums on time will cause my policy to lapse.

I authorize Mathebula Community Society to arrange with my bank account for the amount above mentioned to be deducted from my account in accordance with the debit system. This authority may be cancelled by me giving Mathebula Community Society thirty days’ notice in writing sent by registered post, but I understand that I shall not be entitled to any refund of amounts which Mathebula Community Society have withdrawn while this authority was in force if such amounts were legally owing Mathebula Community Society

MATHEBULA COMMUNITY SOCIETY
CANON WORSHIP CENTRE CHURCH TEMBISA FOR DIRECTION
No: 421 NYARHI & SIMUNYE STREET – OAKMOOR (CLOSE TO TRAIN STATION)

TELL: 011 383 2241 / 015 581 6061
CELL: 083 756 8946/065 733 5501 / 078 924 8736
FAX: 086 683 2373
EMAIL: info@mathebulacs.co.za
Reg: 2019/612222/07

NAME: MATHEBULA COMMUNITY SOCIETY BANK: FNB

BRANCH: 250655 BRANCH: TRAMSHED MALL ACCOUNT

NUMBER: 62838772946

• All members are to complete membership application forms. Beneficiaries may be nominated.
• The premium has four months waiting period before a claim can be approved.
• There is a twenty-four (24) months waiting period on death due to suicide.
• Two months waiting period will apply for Accidental death.
• The original or a Certified copy of the original death certificate of the Assured Life; proof of identity of the Assured Life; either the policy certificate, if available, or the application form; an official police report in the case of the death of the Assured Life due to unnatural causes.
• All monthly premiums are payable within no later than the date which the client has agreed/signed on the document (from 1^st – 7^th of every month).
• If you skip 1(one) month’s premium then you must t pay double before the 7^th of the following month and the policy will remain in force.
• If you skip 2 (two) months’ premium the policy will be cancelled and you will start as a new member paying the joining fee and new premium applicable to you according to your age at that time and undergo the waiting period.
• Nobody will be covered without a valid id document passport or asylum seekers permit, a Birth certificate (children) or certified copies thereof.
• Dependants added after the commencement of this policy will undergo the same waiting periods but calculated from the date of their submissions.
• The waiting period will be calculated after the first monthly premium is paid in full.
• Joining fee is free for all our funeral cover/policies. Its advisable that you settle it with your 1^st monthly premium so that your waiting period does not extend to 5 (five) months.
• R250 administration fee will be deducted from every claim
• All deposits slips must be faxed to: (086 683 2373) or Email to: info@mathebulacs.co.za

I, the applicant, declare that according to my knowledge the above information is correct and that I am obliged to abide by the terms and conditions summarized in the scheme information, I understand that failure to pay premiums on time will cause my policy to lapse.

In the event of death, a Claim Notification Form must be completed at our offices and must be submitted together with the relevant supporting documents to the underwriter within six (6) months from the date of death. Failure to do so within the six months will result in the benefit being forfeited.

Documents to be submitted for claim

• This document or participation certificate and proof of premium payments.
• Fully Completed Claim Notification Form
• Fully Completed Police Report Form in case of unnatural cause of death
• Proof of death: (BI-5) original or certified copy, (BI-20) original or certified copy of the Medical Certificate in respect of stillbirths only or (BI-20).
• Certified copy of the Principal Member’s ID document
• Certified copy of the deceased’s ID document or birth certificate in case of child.
• In the event of a claim for a full-time student aged between 21-25 years old, a letter confirming fulltime study at a recognised educational institution must be submitted (part time and correspondence students are not covered as children.

Faxed copies must be clearly certified. The details of the commissioner of oaths with all the relevant details must be clearly legible. Documents submitted other than those listed, will not be accepted. Affidavits are not accepted. The Underwriter serves the right to request any further documents or information it may deem necessary to accurately assess a claim. The underwriter will endeavour to settle the claims within 24 hours of receiving all the required fully completed documents.

I, the applicant, declare that according to my knowledge the above information is correct and that I am obliged to abide by the terms and conditions summarized in the scheme information, I understand that failure to pay premiums on time will cause my policy to lapse.