7/23/2019 My Peace Plan Form

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“Principal Member”The person who is responsible for the payment of the monthly premiums under this Scheme and upon whose death all insured cover on hispolicy Certicate will cease.

“Beneciary”The person fully described in this policy who has been elected by the Principal Member to receive the Benets or Direct the usage of the

benets claimed as a result of the death of the Principal Member.

“Cancellation”The Principal Member, as well as My Peace Plan reserves the right to cancel this policy at any time after giving the other party one(1) calendar

months written notice of such intentions. The date of cancellation will take effect from the date of service on the recipient's domicilium.

REVISION OF TERMS AND CONDITIONSMy Peace Plan reserves the right to amend, revoke, vary or alter any of the terms and conditions of this policy provided that My Peace Planshall give the Principal Member at least 30 (thirty) calendar days written notice of such revision.• This is a Voluntary Scheme and premiums are payable in advance on or before the 7th of each month.

• Main members who are 18 years or older, to a maximum of 64 years old may participate in the scheme• No restrictions are placed on the size of a family but the insured lives will be limited to those declared on the application form• Customary or common law spouses who are not legally married but are living together as a family can still enjoy family benets provided that

all the relevant particulars are declared on the application form.• Unmarried children under the age of 21 are covered. Cover is extended up to, but not including the age 26 if the child is an unmarried full

time student. Cover for physically or mentally challenged children is subject to a six (6) calendar month waiting period as stipulated in the

Master Policy.• Cover for all members selecting R10 000 and R15 000 covers are subject to a six (6) calendar month waiting period• Cover for all members selecting R20 000 and R30 000 covers are subject to a twelve (12) calendar month waiting period• Death as a result of suicide is subjected to a 24 months waiting period.

• Immediate cover is granted for accidental death after the rst Premium is received by the Underwriter.• Cover under the scheme will cease in respect of a particular member when premiums are not paid on time and received by African Unity

Insurance.• If a members' cover should cease and the member applies to re-join the scheme at a later stage, the same conditions as for new

membership will apply.• Cover under the scheme is provided for on a month-to-month basis. No reserves are built up under the scheme, therefore premiums are

payable lifelong and there are no surrender values when cover ceases• Premiums under the scheme are not guaranteed and can be adjusted by the insurer at any stage.• If a member increases his/her cover under the scheme, the increased cover amount will be subject to the relevant waiting period of 6

Months, before the full cover commences.• Membership under the scheme can only commence on the 1st day of a month.

• If application to the scheme falls within the middle of a month, membership to the scheme will only commence on the 1st day of the

new month.• Application for membership is restricted to a maximum entry age of 64 years for the main members and 79 years for any extended familymember at commencement.

• Only claims submitted within six (6) months of the date of the death will be considered for payment.

• No claim will be honoured if premiums are in arrears or short paid.• Claims for common-law spouses NOT declared on the initial application form will NOT be considered for payment in the event of death

(Traditional marriages – Lobola – included).• NO claims in respect of grandchildren or foster children will be considered, unless proof of legal adoption has been supplied or if the child is

registered as an extended member.• A ten (10%) administration fees of the complete cover amount will be charged on all claims.

“Cooling off Period” The Applicant shall have the option to cancel this Policy within a thirty (30) day period effective from the date of receipt of the rst monthlypremium

IMPORTANT WARNINGThe Products or Transactions chosen by the applicant are deemed to meet his/her needs and requirements. To this end, it is proposed that theApplicant engages the Intermediary or insurer with regard to the impact of the proposed transaction on his/her nances, other insurance and

insurance Policies or broader investment portfolio. The Applicant is advised to complete and sign all requisite forms after ensuring that he/sheunderstands the content thereof. The Applicant is invited to request information, of any nature whatsoever, whether verbal or written, relative tothis Policy. Any concerns regarding the product sold may be addressed to either the long term insurance Ombudsman or the Registrar of Longterm Insurance, whose details are set out below, if the Applicant has concerns regarding the products sold and/or advice given to him.

DETAILS OF THE UNDERWRITER DETAILS OF THE FINANCIAL SERVICES

PROVIDER

DETAILS OF THE OMBUDSMAN DETAILS OF FINANCIAL

SERVICES BOARD

ZINMAR CORPORATE CONSULTANTS

appoints: AFRICAN UNITY INSURANCEas the UNDERWRITER of their Policy

the My Peace Plan Group Scheme

With ofces at: Riesling House, DorpStreet, Vineyard Ofce Estate, Bellville 7530’

Tel no: 021-913 9240

Email: info@africanunity.co.za

ZINMAR CORPORATE CONSULTANTS

52 18th AVENUEBOSTON, BELLVILLE, 7535

Tel no: 021 949 6021

Email: Zinmar@new.co.zaAuthorised Financial Services Provider 

FSP 14286

Ombudsman for long term Insurance

Private Bag X45, Claremont, 7735Tel no: 021-657 5000

Fax no: 021-674 0951

www.ombud.co.za

Financial Services

Provider P.O. Box 35655, Menlo

Park, 0102

Tel no: 012-428 8000Fax no: 012-347 0221

www.fsb.co.za

Scheme No Peace0001

NAME: SIGNATURE OF APPLICANT: DATE:

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SECTION 1 : To be completed by all applicants, 64 years and younger 

APPLICANT’S DETAILS:

SURNAME FIRST NAMES

TEL NO. CELL NO. OF PREMIUM PAYER

EMAIL OF PREMIUM PAYER SA ID, OR PASSPORT NO

DATE OF BIRTH COUNTRY OF ORIGIN MARITAL STATUS SEX

POSTAL ADDRESS

SUBURB TOWN PROVINCE POSTAL CODE

SECTION 2 : Details of the Applicant’s spouse to be completed here. You may declare a common law spouse or that of a traditional marriage.

SPOUSE’S SURNAME SPOUSE’S FIRST NAME HUSBAND/WIFE DATE OF BIRTH SA ID OR PASSPORT NO

SECTION 3 : Dependents under the age of 21

SURNAME OF CHILD FIRST NAME OF CHILD DATE OF BIRTH SA ID NO OR PASSPORT NO

SECTION 4 : Details of extended family members 79 years and younger 

SURNAME FIRST NAME DATE OF BIRTH SA ID OR PASSPORT NO. RELATIONSHIP RATE

SECTION 5 : Nominated Beneciary Details: ( Beneciary must be older than 16 years of age )

SURNAME FIRST NAME TEL NO. SA ID OR PASSPORT NO. RELATIONSHIP

 

SECTION 6 : DEBIT ORDER INSTRUCTIONS

Please attach a copy of the Applicants Bank Statements/Cheque to ensure correct bank details

BANK BRANCH ACCOUNT TYPE ACCOUNT NAME ACCOUNT NUMBER

CHEQ SAVINGS 

 I hereby authorise African Unity Insurance (AUI) to draw against my account with the above mentioned

bank (or any other bank or branch to which I may transfer my account) the amount necessary for

payment of the monthly Premium due in respect of this Funeral Insurance Policy. All such withdrawalsfrom my Bank account for this purpose shall be treated as though they had been signed by me

personally. Should my account fall in arrears, I authorise AUI to increase my monthly premium to coverthe arrears within the contract period. I understand that the withdrawal hereby authorised will be

processed by computer through a system known as Bankserve or any other electronic means and Iunderstand that details of which will be printed on my bank statement or an accompanying voucher. I

agree to pay any and all bank charges that relate to this debit order including, without derogating from

the general hereof, all lodgement, failure and other costs that AUI may incur. Receipt of this instructionby AUI shall be regarded as receipt thereof by my Bank.

Benets Option(Select 1)

Cover(Select 1)

Premium

Individual 

Family

EXTENDED FAMILY MEMBERS(IN SA ONLY)

ADDITIONAL BURIAL COVER(IN ZIMBABWE ONLY)

TOTAL

For more info SMS PEACE to 40439 | info@peaceplan.co.za | 021 013 0111 Capetown  | 011 079 1664 Johannesburg

Underwritten by African Unity Insurance Limited, FSP 8447 and administrated by Zinmar Corporate Consultants FSP 14286

My Peace Plan is a juristic representative of ZINMAR CORPORATE CONSULTANTS

3 Stonehill Estate,Protea Village, Bergroos St Brackenfell, Capetown | 209 Bellairs Drive Northriding Johannesburg

NAME: SIGNATURE OF APPLICANT: DATE:

NAME: SIGNATURE OF PAYER: DATE:

Powered by My Peace PlanUnderwritten by African Unity FSP 8447 and administered

By Zinmar Corporate Consultants, FSP 14286My Peace Plan is a juristic representative of

 ZINMAR CORPORATE CONSULTANTS

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