The Cornerstone Pensioner Funeral Plan - Assupol | A Proudly South African Insurance ... ·...
Transcript of The Cornerstone Pensioner Funeral Plan - Assupol | A Proudly South African Insurance ... ·...
The Cornerstone Pensioner Funeral Plan
My name
Tel (012) 685 8300Fax (012) 685 8315
My intermediary My intermediary’s telephone number
CORNERSTONE
Cornerstone Pensioner Plan
CORNERSTONE IS AN AUTHORISED FINANCIAL SERVICES PROVIDER
About you, the policyholder
Gender male femaleTitleSurname
Full first names
ID Marital status
Cell
E-mail State grant
Alternative cell
single married divorced widowed
Initials
Street or postal address
Postal code
Policy number
1 Cornerstone Pensioner Plan application
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 applicable blocks are marked clearly with an X, and then sign the form. Important: you must take out the main benefit. You cannot take out an extra benefit without taking out the main benefit.
Application form
About your beneficiaryThis is the person you appoint to claim and receive the policy benefits after your death. He or she must be 18 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.
Relationship to you
Full first names
Gender male femaleTitleSurname Initials
ID
disability grant old age grant
25 April 2018
21
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.
What are your needs?
1. Do you need funeral cover?
2. Do you have funeral insurance?
3. If yes, how many funeral policies do you have?
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. You will have additional benefits?
4. Other reasons?
yes no
yes no
R
R
yes no
yes no
yes no
4. How much is your total funeral cover?
5. How much is your total monthly premium?
6. Do you want to add lives insured?
R70 R80 R120R90 R130R100 R140R110 R150Monthly premium
R8 550
R8 150
R4 100
R3 000
Total benefit
R9 200 R14 000
R8 900 R13 600
R4 450 R6 800
R3 350 R5 100
R10 050 R15 150
R9 700 R14 700
R4 850 R7 300
R3 650 R5 500
R11 300 R16 300R12 650 R17 400
R10 950 R15 800R12 250 R16 900
R5 450 R7 900R6 100 R8 450
R4 100 R5 950R4 600 R6 300
18 - 64 years
65 - 69 years
70 - 79 years
80 years & above
Age group
Mark monthly premium you choose (grey block) with an X.Total
benefitTotal
benefitTotal
benefitTotal
benefitTotal
benefitTotal
benefitTotal
benefitTotal
benefit
A - Your main benefit
RRYour main benefit monthly premium RYour main benefit monthly premium (A)
Benefits and premiums you may select
yes no
2 Cornerstone Pensioner Plan application
This benefit provides income in the first three or five months after your death. The first payment is made at the end of the month in which you die. Mark monthly premium you choose (grey block) with an X.
R20
Total benefit
R570 per monthfor 5 months
R1 140 per monthfor 5 months
R1 710 per monthfor 5 months
R2 280 per monthfor 5 months
R2 550 per monthfor 5 months
R520 per monthfor 5 months
R1 040 per monthfor 5 months
R1 560 per monthfor 5 months
R2 080 per monthfor 5 months
R2 350 per monthfor 5 months
R490 per monthfor 3 months
R980 per monthfor 3 months
R1 470 per monthfor 3 months
R1 960 per monthfor 3 months
R2 200 per monthfor 3 months
R350 per monthfor 3 months
R700 per monthfor 3 months
R1 050 per monthfor 3 months
R1 400 per monthfor 3 months
R1 580 per monthfor 3 months
C - Your Family Care benefit Optional extra benefit
Monthly premium
18 - 64 years
65 - 69 years
70 - 79 years
80 years & above
Age group Total benefit Total benefit Total benefit Total benefit Total benefit
R40 R60 R80 R90
Policy number 21
RRYour main benefit monthly premium RYour Family Care benefit monthly premium (C)
One spouse may be covered
ID
Your spouse is (a) the person to whom you are legally married under the law of South Africa including a civil, customary or same-sex marriage, –or (b) the person you have been living with for at least six months in a relationship that is similar to marriage, and intended to be permanent like a marriage.
Gender male femaleTitle Initials
Surname
Full first names
B - Your Dependants benefit Optional extra benefit
Up to eight children may be covered
ID number Gendermale
male
male
male
male
male
male
male
female
female
female
female
female
female
female
female
Full first names and surname1
2
3
4
5
6
7
8
Mark monthly premium you choose (grey block) with an X.
Your Dependants benefit monthly premium (B)(Premium for spouse + children)
R
R10
R2 000
Spouse
R8 000 R2 400R4 000 R2 000R2 666 R1 710R2 000 R1 500Cover
Dependants2
children3
children4
children5
children6
children7
children8
children1
child
Monthly premium R20 R30
Mark monthly premium you choose (grey block) with an X.
R20
R2 850
R2 600
R1 500
R1 050
D - Your Tombstone benefit Optional extra benefit
Monthly premium
18 - 64 years
65 - 69 years
70 - 79 years
80 years & above
Age group Total benefit
R40
R5 700
R5 200
R3 000
R2 100
Total benefit
R60
R8 550
R7 800
R4 500
R3 150
Total benefit
R80
R11 400
R10 400
R6 000
R4 200
Total benefit
R90
R12 850
R11 700
R6 750
R4 725
Total benefit
Your Tombstone benefit monthly premium (D) R RRYour main benefit monthly premiumRYour total monthly premium (A+B+C+D)
25 April 2018
3 Cornerstone Pensioner Plan application
Policy number 21
How the premium will be paid fill in and sign only one of the options below–
Option 1: deduction directly from my state grant Authorization
Surname
Full first names
ID
ym m y yy
Pay station
Deduction start date d d
I hereby instruct the South African Social Security Agency (Sassa) to deduct monthly the above premium from my grant and remit to Assupol Life Ltd.I understand that I am still under an obligation to instruct Sassa to effect the deduction. This must be done at the Sassa local office.I also understand that Sassa does not market or endorse any financial products, and I confirm that I have entered into agreement for a funeral policyof my own free will.
Monthly premium R
Option 2: payment by bank debit order Authorization
Name of branch Branch code
Account-holder Name of bank
Account number 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, the 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.
ym m y yyI will pay from Payment must be made on the day of every month.I will pay by debit order.
Date
My signature or fingerprint ym m y yyd d
Date
Name of grant beneficiary
Grant beneficiarysignature or fingerprint
ym m y yyd d
Date
Name ofintermediary
Intermediary signature
ym m y yyd d
Declaration by you, the policyholder
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.
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? yes no
yes no
Date
My signature or fingerprint ym m y yyd d
25 April 2018
Declaration by you, the policyholder continued
Declaration by the intermediary who assists with this application
I 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.
Initials
Policy number 21
Date
Intermediary’ssignature or fingerprint
ym m y yyd d
4 Cornerstone Pensioner Plan application
Reg no 2010/025083/06 Authorized financial services provider www.assupol.co.za Summit Place Office Park, Building 6, 221 Garstfontein road, Menlyn, Pretoria, 0181 PO Box 35900, Menlo Park, Pretoria, 0102 Compliance department: fax 087 230 5667 e-mail [email protected]
Underwritten by Assupol Life Ltd
Date
Name of intermediary supervisor
Intermediary supervisor signature
ym m y yyd d
The intermediary supervisor declares
I am responsible for doing a final overall check of this application form. I have checked that it has been completed and signed properly.
The intermediary code used for this application is the one recorded in the disclosure letter signed by the intermediary who assisted with this application.
Date
Name and surnameof witness
Witness signature or fingerprint
ym m y yyd d
Signature of witness if policyholder is older than 85.
Cell
Province Intermediary code
Surname
25 April 2018
Policy provisions Cornerstone Pensioner Plan – Main policy
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 you or any other person you insure under this policy. You must have an insurable interest in all lives insured under this policy. You have, for example, such an interest in your spouse and children.
When cover and waiting periods start
For every life inured 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.
During a waiting period, premiums must be paid in full, but full benefits are not provided. After the waiting period, the full benefits are 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 lives insured when cover starts
Unless you are a social grant recipient, you must be 60 or older to take out this policy. You may insure one spouse under this policy. The spouse must be 18 or older but under 65. You may insure up to eight children under this policy. They must be under .21
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 the following maximums: R10 000 if the insurance is taken out when the person is under age 6; R25 000 if it is taken out when they are 6 years or older, but under age 18; R50 000 if it is taken out when they are 18 years or older, but under age 65; and R15 000 if they are 65 years or older. 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 three 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.
Other things to know
You must tell us immediately if any information changes or if you want to add or remove a life insured. The provisions of this policy are in accordance with the Long-term Insurance Act. We will never collect a joining fee from you. Applying for this policy is optional, and does not affect your right to receive social grants. 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 ages 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 the policy at any time by written notice to us. If we receive your notice within 30 days after you receive 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.
Main policy R500 is payable for natural death within the first three months after start of the policyR750 is payable for natural death within the fourth, fifth and sixth month after start of the policy
R500 is payable for natural death within the fourth, fifth and sixth month after start of the policy
No benefits are payable for suicide within the first 24 months after start of the policy
No benefits are payable for suicide within the first 24 months after start of the policy
The total benefit is payable for accidental death
The total benefit is payable for accidental death
R250 is payable for natural death within the first three months after start of the policy
Tombstone
Family Care
Dependant benefit
Reg no 2010/025083/06 Authorized financial services provider www.assupol.co.za Summit Place Office Park, Building 6, 221 Garstfontein road, Menlyn, Pretoria, 0181 PO Box 35900, Menlo Park, Pretoria, 0102 Compliance department: fax 087 230 5667 e-mail [email protected]
Underwritten by Assupol Life Ltd
Policy provisions continued
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 0861 329 287 post PO Box 35900, Menlo Park, Pretoria, [email protected]
Complaints
Our commitment is to provide excellent service to you. Should it happen that you, after having contacted one of our offices or our client-services department, are still not satisfied, please contact our complaints department:tel 087 098 0290 e-mail fax 087 230 5669 post PO Box 35900, Menlo Park, Pretoria, [email protected]
If, after you have contacted our complaints department, you are still not satisfied, you could approach the:
Fais Ombud – about the conduct of the intermediary who assisted youfax 012 348 3447 e-mail [email protected] PO Box 74571, Lynnwood Ridge, Pretoria, 0040
Ombudsman for long-term insurance – about an aspect of your policyfax 021 674 0951 e-mail [email protected] Private Bag X45, Claremont, 7735
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Cornerstone Pensioner Plan – Main policy
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