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Minimum age 18 years & maximum age 65 years



The beneficiary below will receive the benefit when the Principal Insured dies


Product & Cover amountCoverPremium
Product R 90.00


NameSurnameID NumberID Type


NameSurnameID NumberID Type


I / We hereby authorise African Unity Life Ltd or any of its legal representatives / agents (hereafter referred to as "you") to issue and deliver payment instructions to your banker for collection against my|our below mentioned account at my|our bank (or any other bank to which I|we may transfer my|our account) on condition that the sum of such payment instructions will never exceed my|our obligations as agreed to in the agreement and commencing on and continuing until this authority and mandate is terminated by me / us by giving you one calendar month's written notice. The individual payment instructions so authorised to be issued must be issued and delivered monthly (on the day of every month). In the event that the payment day falls on a Sunday, or recognised SA public holiday, the payment day will automatically be the very next ordinary business day. I / We understand that the withdrawals hereby authorised will be processed through a computerised system provided by the SA Banks. I also understand that details of each withdrawal will be printed on my bank statement. I / We acknowledge that all payment instructions issued by you shall be treated by my|our below mentioned bank as if the instructions have been issued by me/us personally. I / We agree that although this authority and mandate may be cancelled by me / us, such cancellation will not cancel the agreement. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were leally owing to you. I / We acknowledge that this authority may be ceded or assigned to a 3rd party if the agreement is also ceded or assigned to that 3rd party, but in the absence of such assignment of the agreement, this authority and mandate cannot be assigned to any 3rd party.


I hereby apply for the benefits contained in this member application form and I declare that I have not witheld any material information. I accept that this member application and declaration shall be the basis of the agreement between African Unity Life and myself. I understand that any inaccurate, false or untrue statement may render my policy null and void and all premiums paid will be forfeited to African Unity Life. I understand that the policy will only come into effect after African Unity Life has received my 1st premium. I understand that claims will not be paid to the beneficiary if all my premiums have not been paid to AFRICAN UNTIY LIFE. I have been informed of my rights of the policy protection rules and I declare that I understand and accept the terms and conditions applicable to this policy. I further declare that:

  • The information supplied on this member application form is true, complete, accurate and correct
  • I consent to the processing of my personal information, including the sharing of information for purposes of implementing this policy
  • The benefits, terms and conditions of this policy have been explained to me and that I understand and accept them
  • The monthly premium is affordable and that I can afford to pay for this policy
  • My bank details are correct for the deduction of my monthly premium via debit order (if applicable)
  • I understand and accept the terms and conditions of any add-on product that I have selected
  • I can request to see a copy of the Master Policy that is held by the Policyholder (scheme owner)
  • I understand that should this policy be replaced by any other similar policy I am required to complete and sign a Replacement Policy Advice Record, to be submitted to the Insurer.
  • I will receive a participation certificate ,containing a summary of my policy terms and conditons.
  • I understand and accept the contents of this declaration with my signature below