The Cornerstone SolutionSingle Funeral Plan - Debit order

My name

Tel (012) 685 8300Fax (012) 685 8315

My intermediary My intermediary’s telephone number

Single Funeral Plan – main policy Debit-order application form

The Cornerstone Solution

About you, the policyholder

Benefits and premiums you may select

Please make sure that you understand this entire form, as well as the policy provisions provided with it. Complete all pages carefully, making sure that all blocks selected are marked clearly with an X, and then sign the form. We will consider your application according to our underwriting rules and practice. Tell us immediately if any information changes. You and we (Assupol) are the only persons involved in entering into this policy.

CORNERSTONEPolicy number

1

About the main life insured, if you are not a life insured

Surname

Relationship to you

Full first names

ID

Gender male femaleTitleSurname

Full first names

ID Marital status

Tel (work) ( )

Tel (home) ( ) E-mail

Cell

single married divorced widowed

Initials

Street or postal address

Postal code

RTotal monthly premium

Single plan 18 - 64 years

Cover

Monthly premium

Plan A

R 6 000

R 50

Plan B

R 12 000

R 85

Plan C

R 18 000

R 110

Mark monthly premium you choose with an X.

Cornerstone Solution Single debit-order application form

ym m y yy

Name of branch Branch code

Account-holder Name of bank

I will pay from

Account number

Payment must be made on the

Type of account transmissioncurrent savings

I authorize Assupol to draw the premiums from my bank account. If the premium changes for any reason in terms of the policy, or by agreement between Assupol and the policyholder, the changed premium may likewise be drawn from my bank account. If payment cannot be done on the preferred day of the month filled in above, it must be done on a day that is as close as possible to that day, determined by Assupol. If the policy ends, this authorization also ends. I may cancel, amend or replace this authorization by written notice to Assupol. I accept that Assupol must receive the notice not later than 30 days before the month from which the cancellation, amendment or replacement is to apply. The reference on your bank account statement will start with: Assupol.

day of every month.I will pay by debit order.

How the premium will be paid Authorization

My signature Date d ymd m y yy

02 May 2018

CORNERSTONE IS AN AUTHORISED FINANCIAL SERVICES PROVIDER

Policy number

2 Cornerstone Solution Single debit-order application form

About your beneficiary

Declaration by you, the policyholder

Declaration by the intermediary who assists with this application

My signature

Intermediary’s signature

Date

Date

d ymd m y yy

d ymd m y yy

This is the person you appoint to claim and receive the policy benefits after your death. He or she must be 18 years or older. You may change your beneficiary at any time for example, if you get married or divorced. If for any reason payment cannot be made to your beneficiary, we may pay the –amount required for the life insured’s funeral to the undertaker who handles the funeral or to the person who proves that he or she has paid for the funeral. Any remaining benefits will be paid to your deceased estate.

I declare that all information in this form is complete and correct, and that I received a signed copy. I am satisfied that I understand everything I need to know about the policy and my funeral needs analysis above, and that I will be able to pay the premiums. I understand that if information is not correct, benefits under the policy may be declined and premiums paid could be forfeited.

Analysis of your funeral needs

It is important that you have the right and enough funeral insurance to meet your and your family’s needs. To achieve this, it is necessary to analyze your funeral insurance needs. Your intermediary must complete this needs analysis.

Companies in the Assupol group of companies may from time to time offer other products or services to me.

Are you taking out this policy to replace any of your existing insurance policies?

Gender male femaleTitle

Surname

Relationship to you

Full first names

ID Initials

I have checked that this form has been properly completed and signed. I discussed it, and the policy provisions provided with it, with the policyholder. I have not given, and will not give, money or anything of value to the policyholder or a life insured as an inducement to take out this policy. I explained to the policyholder the implications of replacing insurance.

I informed the policyholder that, for services rendered in respect of this application and the policy, Assupol pays to Cornerstone a once-off commission equal to the first month’s premium, and a recurring commission equal to 24,5% of every monthly premium.

What are your needs?

1. Do you have funeral insurance?

2. If yes, how many funeral policies do you have?

3. How much is your total funeral cover?

Why will the product you are applying for meet your needs?

1. You and your dependents will have funeral cover?

2. Your funeral cover will increase to the amount you need?

3. Other reasons?

yes no

yes no

yes noR

R

yes no

yes no

4. How much is your total monthly premium?

5. Do you need funeral cover?

6. Do you want to add lives insured?

Province SurnameCode Initials

yes no

yes no

02 May 2018

Your policy, and our contractual commitment, takes effect when we (Assupol) accept your application for the policy. Your application form and these policy provisions are the complete and only record of your policy, and also the summary of your policy required by section 48 of the Long-term Insurance Act.

Life insured

This is a person whose life is insured under your policy. This is you, or the main life insured. You must have an insurable interest in the main life insured. You have, for example, such an interest in your spouse, children, parents and other family members.

Main life insured

This is the person whose life you insure under your policy, if your life is not insured under the policy.

When cover and waiting periods start

For every life insured death cover for an accidental death starts, and the waiting period for death cover for natural (non-accidental) death and suicide starts, on the first day of the month in which the first monthly premium for cover for that life insured is due.

The waiting period for natural death is six months. For suicide it is 24 months. During a waiting period premiums must be paid, but benefits are not provided.

Accidental death is death caused by an incident that causes harm to the body of the life insured from outside the life insured, which harm excludes any sickness – and which incident and harm the life insured did not intend and reasonably could not have foreseen. The incident must be the direct and only cause of death, and death must happen within 30 days after the incident.

Age of life insured when cover starts

You, and the main life insured, must be under age 65.

Maximum funeral cover for one person

When a person takes out funeral insurance with us, the total funeral cover for that person under all individual and group policies with us may not be more than a maximum of R50 000. Any cover above the maximum automatically falls away.

About your premiums

The premium for your policy is payable monthly, before the end of every month. The premium we receive in a particular month provides cover for that month. The premium pays for death cover only, and not for any investment or cash value. Premiums are not refunded if your policy ends for any reason.

If two monthly premiums in a row are not paid, and both are not paid by the end of the month in which the second premium should have been paid, your policy ends automatically. If within 12 months of your policy ending, we again receive a premium, we may reinstate your policy, and new waiting periods will then apply.

If premiums are not paid in full, benefits also cannot be paid in full. Only a percentage of the benefit can then be paid namely a percentage that –is the same as the percentage of premiums paid. For example, if you had to pay premiums of R1 000, but paid only R500, it means you paid only 50% of the premiums. Therefore, only 50% of the benefits can then be paid. So, if the benefit amount is R10 000, only R5 000 can be paid.

When policy benefits will not be paid

A benefit will not be paid if information (for example, about your relationship with lives insured or the age of lives insured), was not provided to us before the start of the benefit in question, or is not correct.

A benefit will also not be paid if the life insured’s death is caused or accelerated directly or indirectly by war, civil commotion or terrorist activity, or if the life insured dies while committing a criminal activity.

You can cancel your policy

You can cancel your policy at any time by written notice to us. If we receive your notice within 30 days after you have received these policy provisions, your policy ends when we receive your notice. This is known as a cooling-off cancellation. If we receive your notice after the 30 days, your policy will end at the end of the month in which we receive your notice, and then premiums received after the policy has ended will be refunded.

The actuarial basis of your policy

Your policy operates according to actuarial rules, specifications and formulae, which are approved according to law, and which are known as the actuarial basis of your policy. This ensures that your policy is financially sound, and is carried out properly and fairly.

Policy provisions The Cornerstone Solution Single Funeral Plan–

Policy provisions continued The Cornerstone Solution Single Funeral Plan–

Information about you

We and Cornerstone may use information about you, also personal information meant in the Protection of Personal Information Act, that we lawfully obtained in the past or may obtain in future, including the information provided for your application for this policy, for the following purposes:

· to consider applications for insurance of which you are the policyholder or a life insured; and· for all purposes of such insurance, issued in the past or in future, particularly to consider claims for benefits and to trace persons who could receive benefits.

We may for these purposes, at any time, also after your death:

· obtain such information from other persons and entities, particularly from other insurers and registered credit bureaus, and you authorize them to give such information to us;

· share such information with other insurers – directly or through a data base that insurers operate as a group, and in such form as we or the operators of the data base may decide.

How to claim a policy benefit

Visit any of our offices, set out on the back of this folder, or phone 0861 235 664. Our offices are also open on Saturdays from 08:00 to 13:00.

We must receive a completed claim form within six months, after the death of the life insured. The persons who claims must, at their own cost, prove the claim, show that no exclusions apply, and give us all information and documents we need to consider the claim.

This must include:· the claim form completed and signed as required–· certified copy of the valid ID document of the person who claims· certified copy of the original death certificate of the life insured – form DHA 5· certified copy of the valid ID document of the life insured, with “deceased”or a similar notice stamped on it· copy of the notification/registration-of-death – form DHA1663· copy of a valid bank statement of the person who claims, not older than three months, showing the account-holder and the account number· police report if the death is due to unnatural causes for example, a motor-vehicle accident–· other documents that we may reasonably require.

For other assistance

Visit any of our offices, or contact our client services department:tel 0861 235 664 e-mail fax post clientservices@assupol.co.za 0861 329 287 PO Box 35900, Menlo Park, Pretoria, 0102 Complaints

Our commitment is to provide excellent service to you. If, after having contacted one of our offices or our client-services department, you are still not satisfied, please contact our complaints department:tel 087 098 0290 e-mail fax complaints@assupol.co.za 087 230 5669 post PO Box 35900, Menlo Park, Pretoria, 0102

If, after you have contacted our complaints department, you are still not satisfied, you could approach the:

•

•

•

•

•

•

Reg no 2010/025083/06 Authorized financial services provider www.assupol.co.za Summit Place Office Park, Building 6, 221 Garsfontein road, Menlyn, Pretoria, 0181 PO Box 35900, Menlo Park, Pretoria, 0102 Compliance department: fax 087 230 5667 e-mail compliance@assupol.co.za

Underwritten by Assupol Life Ltd

Fais Ombud – about the conduct of the intermediary who assisted youfax 012 348 3447 e-mail info@faisombud.co.zapost PO Box 74571, Lynnwood Ridge, Pretoria, 0040

Ombudsman for long-term insurance – about an aspect of your policyfax 021 674 0951 e-mail info@ombud.co.zapost Private Bag X45, Claremont, 7735

Assupol and Cornerstone branches

BergvilleBergville Central ArcadeShop 8 4 Broadway street

BloemfonteinDia House148 Zastron streetBloemfontein 9300

BochumStand 526Extension 3SenwabarwaneBochum 0790

Cape Town 5th St Georges Mall Building

20 Adderley streetShop 8

Cape Town 8000

DurbanRedefine Towers1st floorShop 105-110320 Dr Pixsley Kaseme streetDurban 4001

East LondonGround floor91 Western avenue

Emanguzi

Empangeni

Lykouria Investments Complex

1 Pearce road

Shop 3A

Empangeni 3880

ErmeloKWB BuildingGround floorOffice 8

Gelegele road

22 De Clerq street

Ekuthukuzeni area

Ermelo 2351

Manguzi/Kwangwanase 3973

GiyaniMasingita Shopping CentreShop 11 cnr Malamulele & Main roadGiyani 0826

BethlehemShop 136B Roux street Bethlehem 9701

Bergville 3350

Burgersfort133 Morone Shopping CentreShop 38BKastania streetBurgersfort 1150

BushbuckridgeEagles Business CentreShop 106Stand 4R40 roadBushbuckridge 1280

De Aar Novel Building

23 Main street1st floor

De Aar 7000

EerstehoekPholani TarvenStand 11 & 12B Enhlazathe 5Elukwatini 1192

EscourtSlades ArcadeShop 6A127 Albert streetEstcourt 3310

EshoweFour Square BuildingShop 8BOsbourne roadEshowe 3815

GreytownNew March Building151 Pine street Greytown 3250

GroblersdalMedical Centre14 Kruger street Groblersdal 0470

Jane FurseStand 28Welgelegen Schoord roadJane Furse 1085

JohannesburgNewtown Junction MallShop 161 100 Carr streetNewtown

IxopoShop 525 Margaret street Ixopo 3276

KamhlushwaSDK Catering & ConfectioneryStand 1642 Kamhlushwa 1332

Kempton ParkFestival MallShop 34 cnr CR Swart drive & Kelvin streetEsther Park Kempton Park 1619

KimberleyChapwood Chambers15 - 17 Chapel street Kimberley 8301

King William’s TownMarket SquareGround floor Shop 8AMaclean street King William’s Town 5600

KlerksdorpWest End CentreGround floor Office 29A51 Leask street Klerksdorp 2571

Kokstad76 Hope streetKokstad 4700

Kroonstad41 Buitekant streetKroonstad 9499

Kuruman7A Steward streetKuruman 8460

KwaggafonteinSite 25Section C 26 Mkobola streetEmpumalanga Kwaggafontein 0458

LadysmithChristopher ArcadeShop 4 133 Merchison streetLadysmith 3370

LephalaleCarbo BuildingShop 6 3 Kort streetLephalale 0555

LusikisikiLusikisiki PlazaShop 25 & 26 Lusikisiki 4820

MabopaneCentral HouseSuite 204 2nd floorAccess road Mabopane 0190

MahikengShasons CentreOffice 7 46 Shippard streetMahikeng 2745

MarapiyaneMolai Shopping CentreShop 13 Stand 2823Neu HalleMarapiyane 0431

MbombelaNelcity CentreShop U6 & U7 cnr Paul Kruger &Samora Machel driveMbombela 1200

MelmothElsabas CentreShop 14 Symmonds streetMelmoth 3835

MiddelburgSteve Dickenson Building22 Bhimay Dimane street Middelburg 1055

Mitchell’s PlainLiberty Promenade Shopping CentreShop C04 AZ Berman driveMitchell’s Plain 7785

MkuzeMkuze Station Shopping CentreShop 6 Falcon streetMkuze 3965

Modimolle105 Albert Luthuli streetModimolle 0510

MogwaseJR CentreRoom 2 & 3 Stand 965 Unit 3 JR Building Shopping Complex road Mogwase 0314

Mokopane42 van Riebeek streetMokopane 0601

MthathaShop 60, 62 & 64BT Ngebs City Mall Mthatha 5100

MtubatubaOriole CentreUnit 3G 30 Jan Smuts avenue Mtubatuba 3935

Newcastle50 Sutherland streetNewcastle 2940

NkandlaKFC BuildingRoom 4 Ndlangubo streetNkandla 3855

NongomaNongoma Medical CentreShop 2 1 Main roadNongoma 3850

NqutuNqutu Abenguni BuildingLot 57 Mdlalose streetNquthu 3935

PhalaborwaFCM BuildingOffice 8B 20 Wildevy avenuePhalaborwa 1390

PhuthaditjhabaNaledi MallOffice 102K Phuthaditjhaba 9866

Pietermaritzburg221 Pietermaritz streetPietermaritzburg 3201

Piet RetiefBohmer Centre1st floor Office 19cnr Mark & De Wet street Piet Retief 2380

PinetownCharter House2nd floor Suite 20475 Crompton streetPinetown 3600

Polokwane28C Schoeman streetPolokwane 0699

Pongola223 Klasie Havenga streetPongola 3170

Port Elizabeth223 Cape roadMill Park Port Elizabeth 6001

Port ShepstoneCowrie CourtShop 1 Nelson Mandela drive Port Shepstone 4240

Potchefstroom84B Walter Sisulu streetPotchefstroom 2531

Pretoria City CentreTomkor BuildingShop 5 101 Du Toit streetPretoria 0001

Queenstown46 Cathcart roadQueenstown 5319

Rustenburg31 Steen streetRustenburg 0299

SoshanguveShop 102Richard Thorntree Shopping Centre cnr Hebron road & Umphafa roadSoshanguve - VV Township 0164

SowetoMaponya MallShop 341 2127 Chris Hani roadKlipspruit extension 5 Soweto 1809

StandertonThe Pillars Building14A Mbonani Mayisela street Standerton 2430

Stanger54 Chief Albert Luthuli streetStanger 4450

TaungTaung Forum BuildingOffice 01/01D Station roadTaung 8584

ThohoyandouLimDev BuildingOffice 79 & 81 Block CPost Office street Thohoyandou 0950

TzaneenCRS MallShop 1 32 Skirving streetTzaneen 0850

UlundiShop 1930 Princess Magogo street Ulundi 3838

UmzintoArchibald BuildingShop 3 Ixopo roadUmzinto 4200

Upington33 Schroder streetUpington 8801

VereenigingMarkpark Shopping CentreShop S2A cnr Voortrekker street Beaconsfield avenue Vereeniging 1930

VryheidEmpire BuildingOffice 1 1st floor 118 Hoog street Vryheid 3100

VryburgDu Plessis SentrumShop 7 Stand 213724 De Kok streetVryburg 8601

Welkom147 Investment CC BuildingShop 3 324D Stateway streetWelkom 9459

WorcesterQuenet’s ArcadeShop 11 72 High streetWorcester 6850

ZeerustLTR Building48 Church street Zeerust 2865

Head OfficeSummit Place Office ParkBuilding 6 221 Garstfontein roadMenlyn Pretoria 0181

VincentEast London 5217

Johannesburg 2000