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FOR SASAWU MEMBERS ONLY!

SASAWU FUNERAL PLAN OPTIONS (Please tick one of the following options)

COVER OPTION 1 OPTION 2 OPTION 3
Member
Spouse 1
Spouse 2
Child(14-21)
Child(6-13)
Child(1-5)
Stillborn-11months
R7500
R7500
R7500
R5000
R2500
R2000
R1000
R14000
R14000
R14000
R5000
R2500
R2000
R1000
R18000
R18000
R18000
R7500
R3000
R3000
R1500
Monthly premium R25 R35 R44
Optional Avis Car, Repatriation & HIV cover. Provides the Main member, Spouse/s and Children by  OPTION  1, 2 or 3 with the Avis Car, Repatriation & HIV Prevention and Protection Benefit. R25
You must select a basic plan if you would like to cover extended family members



MEMBER DETAILS
Surname:*
First Names:*
ID no:*
Age:*
Sex: Marital status:
Postal address:
Cell:*
Tel(h):
Tel(w):
Employer:*
SASAWU membership no.:*Salary pay day



DEPENDENTS' DETAILS
Surname First Name Sex Age
Spouse 1
Spouse 2
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7




Principal member parents to be covered before in-law parents can be covered. Maximum 4 parents.

B. EXTENDED FAMILY BELOW 65 YEARS OF AGE (PARENTS, IN-LAWS, AUNTS, UNCLES, etc.)
Surname First Name Sex Age Relationship R3000 cover R6000 cover R9000 cover R12000 cover R15000 cover Avis Car & Repatriation
1. R22 R44 R66 R 88 R110 R15
2. R22 R44 R66 R 88 R110 R15
3. R22 R44 R66 R 88 R110 R15
4. R22 R44 R66 R 88 R110 R15



C. EXTENDED FAMILY FROM 65 TO 84 YEARS OF AGE (PARENTS, IN-LAWS, AUNTS, UNCLES, etc.)
Surname First Name Sex Age Relationship R2000 cover R4000 cover R6000 cover R8000 cover R10000 cover Avis Car & Repatriation
1. R36 R72 R108 R144 R180 R15
2. R36 R72 R108 R144 R180 R15
3. R36 R72 R108 R144 R180 R15
4. R36 R72 R108 R144 R180 R15



D. EXTENDED FAMILY OVER 85 YEARS OF AGE (PARENTS, IN-LAWS, AUNTS, UNCLES, etc.)
Surname First Name Sex Age Relationship R2000 cover R4000 cover R6000 cover R8000 cover R10000 cover Avis Car & Repatriation
1. R50 R100 R150 R200 R250 R15
2. R50 R100 R150 R200 R250 R15
3. R50 R100 R150 R200 R250 R15
4. R50 R100 R150 R200 R250 R15



NOMINATED BENEFICIARY (IN CASE OF DEATH OF THE PRINCIPAL INSURED)*
Surname Initials Relationship ID number
1.



AFFORDABILITY
Gross salary
Deductions