01
Member
Details
02
add
additional
members
03
Beneficiary
details
04
Payer
details
05
policy
confirmation

Please confirm you would like to cancel the sale. Please note this action is irreversible.


Yes
No

I hereby confirm that I have obtained permission from the Payer to debit his/her bank account for the monthly premium payable.


I have authorisation.
Yes
No
INTRODUCTION

Thank you for choosing to buy your Clientèle plan online. We have made it easier for you to get cover at your convenience. In order to complete the form please have your ID number, your income before tax and bank details available. You must be the account holder of the bank account that will be debited.

You can choose the type of plan that will suit your needs based on the list below:

HEALTH EVENT LIFE PLAN (H.E.L.P) PLAN'S OPTIONS: SELECT
1. Standard H.E.L.P Plan – Plans start from R250 per month. Up to R200,000 annual cover; Up to R2,000 Daily Cash benefit. Selected
2. Ultimate H.E.L.P Plan - Plans start from R273 per month. Includes Premium Pay Back Benefit. Up to R200,000 annual cover; Up to R2,000 Daily Cash benefit. Select

Once you have completed all the steps and purchased your H.E.L.P plan your policy documents will be emailed to you, which will have all the details of your new policy.


Please enter your email address in order to start the application or to continue on an existing application.


This e-mail address will be used in all future communications.


continue

Are you sure you wish to remove this child? This cannot be undone.


OK
CANCEL

Are you sure you wish to remove this Beneficiary? Beneficiary allocation percentage must total 100% to continue.


OK
CANCEL

You are . Beneficiary allocation percentage must total 100% to continue.


Our System indicates that you already have a sale in progress would you like to continue or start a new sale?


new sale
Continue

Our System indicates that you already have a sale in progress for would you like to continue with that product sale or start a new sale?


new sale
Continue

Death benefits for children are subject to restrictions and will be paid out as per below table.


Age at claim event Benefit (irrespective of Benefit Amount)
Below the age of 2 R2,500
2 – 5 R5,000
6 – 13 R10,000
14 – 18 100% of the Total Funeral Benefit

Children up to the age of 21 years may remain on the policy provided they are full time students, attending a registered institution (proof of registration will be required at claims stage.)

Annual cover for children is subject to restrictions and will be paid out as per below table.


Age at claim event Percentage of benefit
Up to the age of 4 50%
4-18 100%

In addition Cover for Children under 6 years of age is limited to R10,000 per annum and Cover for Children between 6 and 14 years of age is limited to R30,000 per annum.

Children up to the age of 21 years may remain on the policy provided they are full time students, attending a registered institution (proof of registration will be required at claims stage.)

Member Details
* Mandatory Fields


This e-mail address will be used in all future communications.

How much cover do you want?

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Add Additional Members
* Mandatory Fields

Yes
Please complete personal details for your spouse

save details

Yes
Please complete personal details for your child
Child 1



Children over 18 to 21 must be full-time students.




save details

Yes
Premium Pay Back Benefit – all the premiums of the insured deceased will be paid back.

Please note that Premium Pay Back benefit will be added to all or none of the covered extended members.


Please complete personal details for your extended member
Member 1



Cover Amount (Extended member’s cover amount may not exceed Main Member cover amount)

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Beneficiary Details

* Mandatory Fields
NOTE: Beneficiary allocation percentage must total 100% to continue.
ALLOCATED PERCENTAGE
0%



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* Mandatory Fields
Payer Details
Your Total Monthly Premium:
Is going to be paying the monthly premiums?
Yes
Please fill in your details below.

Bank Details


Authorise
I hereby authorise Clientèle to draw against my bank account the premiums payable monthly, and I request my bank to debit my account in terms of this instruction using reasonable collection methods and tracking for however many days. Should Clientèle not be successful in obtaining the premium, I authorise them to resubmit their request to my bank at any time. I authorise Clientèle to debit my account up to 10 working days before my salary day except for December when the debit could be processed up to 15 working days before my salary day. This instruction will remain in force until cancelled by me. Should the relevant total premium be adjusted by Clientèle as a general increase/decrease in premium, or should I request Clientèle to increase/decrease the premium for certain reasons, I confirm that the adjusted premium may be deducted from my bank account until such time as I cancel this authorisation. Furthermore, I hereby authorise Clientèle to perform the necessary verification, validation and correction of the debit order details, supplied by me, with my bank or other third parties to ensure that this application form can be processed. Resubmission will be applied as aforementioned. The aforementioned debit order transactions will reflect as "CLIENTELE" (together with your policy number) on your bank statement.
I hereby authorise Clientèle to debit my bank account.
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Confirmation

Clientèle Ultimate Funeral Plan
Your Premium
Your Email Adress
This e-mail address will be used in all future communications.
Who is covered
edit
Benefits
Annual increases The premium will increase annually by 10% and the Cover Amount by 6%. Annual increases occur every 12 months from the start date of your policy.
Disclosure, disclaimer, authorisation and declaration


Download Terms and Conditions
I have read and agree with the terms and conditions
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Thank you

Dear valued client, thank you for completing the application for your . Now you can rest assured knowing that your loved ones will be taken care of when you are no longer around.

Your monthly premium will be:

Your policy number is: .


Your documents will be emailed to you shortly. If you have any queries please contact our national call centre on 011 320 3000 or Email: services@clientele.co.za.
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