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


UASA 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
R10000
R10000
R10000
R5000
R2500
R2000
R1000
R14000
R14000
R14000
R5000
R2500
R2000
R1000
R18000
R18000
R18000
R7500
R3000
R3000
R1500
Monthly premium R29 R35 R44
Optional Additional Benefits includes: Avis Car, Repatriation & Protection Benefits. Provides the Main member, Spouse/s and Children by  OPTION  1, 2 or 3 with the Avis Car, Repatriation & and Protection Benefits. R55 pm
Adding Additional Spouses. An Additional fee will be added per Spouse of R21 pm. Select the number of Additional Spouse/s you want to add:
You must select a basic plan if you would like to cover extended family members

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




BEEF BENEFIT
Insured BEEF 1 BEEF 2 BEEF 3
1. Member R4000 R6000 R8000
2. Spouse1 R4000 R6000 R8000
3. Spouse2 R4000 R6000 R8000
R20 per month R40 per month R60 per month



CASKET BENEFIT
Insured CASKET 1 CASKET 2 CASKET 3
1. Member R5000 R10000 R15000
2. Spouse1 R5000 R10000 R15000
3. Spouse2 R5000 R10000 R15000
R25 per month R50 per month R75 per month



CATERING BENEFIT
Insured CATERING 1 CATERING 2 CATERING 3
1. Member R5000 R10000 R15000
2. Spouse1 R5000 R10000 R15000
3. Spouse2 R5000 R10000 R15000
R25 per month R50 per month R75 per month


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