Funeral Services Application

[email protected] | +27 68 194 7205 | +44 7457 403442

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Diaspora Meds Funeral Services Application Form

PROPOSER DETAILS

TitleMrMrsMissDrOther

Surname *

First Name/s *

Effective date of cover *

Date of Birth *

National I.D/ Driver’s License/ Passport No *

Cell phone details: *

E-mail address *

Street Address *

Apartment, suite, etc

City *

Country *

BENEFICIARY FOR OWNERSHIP:

(Not automatically covered unless details are included in section D)

Surname *

Name *

National I.D/ Driver’s License/ Passport No *

Relationship *

Cell phone details: *

E-mail address *

Street Address *

Apartment, suite, etc

City *

FUNERAL BENEFIT PLAN:

(Tick where appropriate)

Select benefit plan *PremiumSupreme

Please give details of everyone to be covered, including self, your family/other dependents.

How many dependents would you like to have covered? *

DETAILS OF EVERYONE TO BE COVERED

Please enter dependent's details:

Surname

First Name/s

GenderMaleFemaleOther

Date of birth

National I.D/ Driver’s License/ Passport No

PackagePremiumSupreme

Declaration

I, the undersigned, hereby declare that the information provided by me and required of me on this application is true and correct and that I understand the product terms and conditions.

I acknowledge that I fully understand the product

YesNo

Contacts:

Phone: +27 68 194 7205

Phone: +44 7455 451551

Phone: +44 3301 330675

Email: [email protected]

Addresses:

SOUTH AFRICA OFFICE:

377 Rivonia Blvd,
Rivonia
Johannesburg
SOUTH AFRICA

UK OFFICE:

11 Andrew Paton Way
Hamilton
UNITED KINGDOM

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Welcome to Diaspora Meds we offer medical insurance and medicine for your loved ones back home. Access to a wide range of medical facilities & services.

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