Funeral Plan Application Form

Applicant Details

Title: Initials: Full Name: Date of Birth: ID Number: Phone Number: Email Address: Residential Address: Source of Income:

Salary Pension Government Grant Other

Spouse Details (Optional)

Spouse Name: Spouse Date of Birth: Spouse ID Number: Spouse Phone Number: Spouse Email Address:

Funeral Plan Selection

Plan Type: Cover Amount: Premium Age Group:

Beneficiary Information

Beneficiary Name: Relationship to Applicant: Beneficiary Phone Number: Beneficiary Email Address:

Dependants

Payment Method

Payment Method:

Acknowledgment

I confirm that all the information provided is correct and true.

YMAC - Yelani Consultants (Pty) Ltd t/a YC Solutions company registration nr: 2014/094178/07 is an authorised Financial Services Provider FSP: 45459. Administered by. Structured Risk Solutions an Authorised Financial Services Provider. Company registration Nr: 2016/233252/07 FSP Nr: 50618. Underwritten by Safrican Limited, company registration number 1935/007463/06 a licensed Insurer and Financial Services Provider (FSP: 15123). Copyright Safrican Insurance Company Limited 2023. All rights reserved.