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Contact Details: 0861 11 22 88


1. Principal Member details
Title: Marital Status:
Full Name: Gender:
Surname: Maiden Name:
Race: Date of Birth:
ID No: Tel No:
Cell No: Email:
Postal Address: Postal Code:
2. Spouse Details
Please provide us with information of your life partner or spouse.
Full Name: Date of Birth:
Surname: ID Number:
Gender: Maiden Name:
3. Optional Extended Family Details
Please provide us with information of your children and details of your extended family. Maximum entry age is below 84.
Full Name(s): Surname:
ID Number: Relation:
4. Benefit Selection (please tick selected plan)
Numsa Funeral Plan
Monthly Premium Due: Total Amount Due
(includes R5 admin fee):
5. Payment Method (Authorises NFS to deduct monthly premium for policy taken up with NFS)
Deduct My Salary:
Please note: if you selected weekly, the total amount to be deducted will be divided into four (4) payments and if you selected fortnightly, the total amount deducted will be divided into two (2) payments.
6. Details of Intermediary or Agent
Branch: Name:
Agent Code: Surname:
Please send me info on related products. Are you currently coverd by a similar product?
Does this policy replace an existing funeral product?
Accept the Terms & conditions 
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Numsa Financial Services (Pty) Ltd (Reg No 2010/015839/07) is an authorised financial services provider FSP 43560
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