Individual Application Form

Individual Registration Form

Name

First Name

Last Name

Date Of Birth

Male / Female

Male

Female

ID /Passport Number

Address

City

State/Province

Zip/Postal

Country

Cell Number

Postal Address

Email Address

WhatsApp Number

Work Telephone Number

Name

First Name

Last Name

ID / Passport Number

Relation to Applicant

Name

First Name

Last Name

ID / Passport Number

Relation to Applicant

Name

First Name

Last Name

ID / Passport Number

Relation to Applicant

Name

First Name

Last Name

ID / Passport Number

Relation to Applicant

Name

First Name

Last Name

ID / Passport Number

Relation to Applicant

Benefit Plan

Premium 18-64

Premium 68 - 75

Premium 75 - 84

Name

First Name

Last Name

ID / Passport Number

Relation to Applicant

Name

First Name

Last Name

ID / Passport Number

Relation to Applicant

Name

First Name

Last Name

ID / Passport Number

Relation to Applicant

Name

First Name

Last Name

ID / Passport Number

Relation to Applicant

A Beneficiary is the person you nominate to receive the benefit in the of event of your death. This person must be 18 years or older. Claim payments in the event of your death are payable to the Beneficiary(ies) directly or via Bacarac Group Schemes for onwards payment to the nominated Beneficiary or directly to Lesedi House Funerals, the funeral service provider.

Name

First Name

Last Name

ID Number

Cell Number

Relation

Paragraph

Signature

Clear

Date

Summary of the TERMS AND CONDITIONS

Summary of the TERMS AND CONDITIONS
DEFINITIONS
Accidental Death: Death caused directly by, or resulting from, injuries sustained
due to a sudden and unforeseen event (an accident) which occurs at an identifiable
place, at a set time, which has a visible, violent, and external cause and results in
the death of a Policy Member. Accidental death doesn’t include unnatural causes
or death directly or indirectly relating to an illness.
Applicant / Main Member / Policyholder / Principal Member: An adult person
(18 and older) who legally resides in South Africa and the primary life assured who
qualifies for Cover in respect of the Policy, and who elects to apply for Cover and
agrees to pay the Premium for it.
Application: The form, whether in physical or electronic format, completed by the
Applicant to apply for Cover.
Benefit/s or Policy Benefit/s or Cover: A lump sum Benefit payable to the
Beneficiary/ies in the event of an Insured Event
Beneficiary/ies: A person who is 18 years (or older) and nominated by the Main
Member to receive Policy Benefits due in the event of a valid claim. If no
Beneficiary is nominated by the Main Member or if the Beneficiary is deceased
upon the occurrence of the Insured Event or cannot be located within a reasonable
period of time, King Price Life will in its sole discretion be entitled to pay the
Benefits in the order listed below –
• The Spouse and/or Partner;
• If the Spouse and/or Partner is deceased or no longer qualifies as a Spouse
and/or Partner, the eldest of the Children, provided such Child is over the age
of 18 years; or
• Such other person as King Price Life may in its sole discretion determine.
Child / Children / Dependent:
• Unmarried child of the Main Member or his/her Spouse, under the age of 21
years of age, including a stepchild, posthumous child, an illegitimate child, a
child legally adopted or adopted in terms of customary law, a child under
guardianship of the Principal Member (provided that (i) both biologically
parents of the child are deceased; and/or (ii) the Principal Member can prove
that the child is financially dependent and living with him/her permanently).
• Disabled Child / Children: Unmarried children who are mentally retarded or
totally and permanently disabled prior to age 21, who are unable to care for
themselves are covered to death of the Main Member, cessation age of the Main
Member or withdrawal.
• Stillborn Child: A child of the Main Member and his/her Spouse which is born
dead after the end of the 28th week of pregnancy and not due to an elective
abortion. Only 2 stillbirths claims will be accepted per family during the term
of the Policy.
• Student: A Child under the age of 26 years who is a full-time student (on receipt
of acceptable proof) at a recognised educational institution. This does not
include part-time and correspondence students.
Claimant: A person who submits a claim, whether a Policyholder, Main Member
or Beneficiary.
Cover: A contract in terms of which the Insurer, in return for a premium,
undertakes to provide Policy Benefits upon the occurrence of an Insured event.
Extended Family: Family members dependent on the Main Member for financial
assistance towards the costs of a funeral. The Main Member should have an
Insurable Interest in the life of the Extended This includes the second and
subsequent spouse(s) not covered as a Spouse in terms of the spouse category, the
parent(s), parent's in-law, aunt, uncle, brother, sister, brother in-law, sister-in-law,
cousin, niece, nephew, grandparent or grandchild.
Insurable Interest: A financial- or familial interest in the life of a Policy Member.
Insured Event: The death of the Main Member or any other Policy Members.
Intentional self-inflicted injury: An intentional act of harming one’s own body
without the intention for such injury to be fatal.
Policy Certificate / Document / Schedule: The document, issued to the
Policyholder, that confirms the existence of Cover on the lives of the Main Member
and Policy Members.
Policy Member/s: All the lives assured on the Policy.
Premium: The total monthly amount payable for the Cover, including all
commission and admin costs.
• Up to 55% of the Premium is the financial services fee which is included in the
Premium for the benefit of the Intermediary to provide for data processing fees,
policy administration fees, compliance fees, communication fees, marketing
fees and commission related to this policy,
• The Underwriter receives the value of the Premium less the Financial Services
Fee to underwrite this Policy.
Scheme / Product: Individual products underwritten on a group basis by the
Insurer structured by the Intermediary or Binder holder
Spouse: (i) A person who is the permanent life partner of the Main Member and
who has been financially dependent on him/her for at least 12 months; or (ii) a
spouse or civil union partner in accordance with legislation or the tenets of a
religion generally practiced in South Africa; or (iii) a person who is deemed by The
Underwriter, at its sole discretion, to be the common law spouse of the Main
Member, having regard to the particular circumstances of each case, and shall
include, where applicable, customary marriages or a relationship between two
people of the same gender or the relationship between two people who have lived
together at least twelve consecutive months prior to the date of death of the spouse.
The Underwriter will require satisfactory proof to support any claim.
Suicide: The deliberate act of taking one’s own life.
Waiting Period: The number of months during which no Policy Benefits are
payable as specified, but during which Premiums remain payable.
Wilful exposure to danger: An intentional act that by its nature is potentially fatal,
or an act that a reasonable person should know can be potentially fatal.
TERMS & CONDITIONS:
Cancellation: The Policyholder may cancel the Cover at any time by giving 31
days’ notice to the Intermediary/ Insurer. In the event of cancellation, the Cover
will continue during the notice period for all Policy Members if Premiums have
been received. The Insurer may cancel the Cover on reasonable grounds at any time
by giving 31 days’ notice, subject to prevailing legislation.
Cession: Cover can’t be ceded, nor assigned or pledged as security in any way.
Cooling off period: The Applicant may cancel his/her policy within 31 days from
the application date, if he/she didn’t claim for a Benefit, all premiums paid up to
that point will be refunded, subject to the cost of any Cover enjoyed
Cover Start Date / Commencement of Cover: A policy commences on the first
day of the calendar month following the receipt of the first premium. If the first
premium is received before the 7th of a month the policy shall commence on the
first day of the same month. If the first premium is received after the 7th of the
month the policy shall commence on the first day of the following month.
Misrepresentation and incorrect details
• If it’s proven that the Cover was based on an incorrect age or date of birth of a
Main Member or any Policy Member, the Insurer may cancel Cover or, at its
discretion, adjust the Cover, Premiums, or both, to what it would’ve been had
it been based on the correct age or date of birth. In the event of a dispute the
decision of the Insurer will be final and binding.
• The information provided and all declarations made by the Applicant, forms the
basis of the Cover. The Cover will be voidable in the event of misrepresentation
or non-disclosure of any fact material to the insurance. Cover won’t be voided
if the incorrect statement was made in good faith, unless the statement
materially affected the assessment of the risk.
Premium Adjustments: The Underwriter reserves the right to adjust Premiums as
determined by the Underwriter’s actuarial control function to the Policy Benefits if
any government, provincial, municipal, or other authority imposes any involuntary
charges, levies, or taxes on the Insurer. To ensure that the Product is actuarially
sound and to ensure profitability and sustainability of the Product for the
Intermediary, the Insurer is entitled to review and increase the Premiums payable
from time to time, but at least annually. The Main Member will be notified 31 days
prior to implementing the increase.
Restrictions and Exclusions:
• Cover restrictions
o Policy Member/s > 14 years: Can’t exceed the Main Member’s Cover up to
a max of R100,000.
o Children aged 6 – 13 years: 50% of Main Member’s Cover up to a max of
R50,000.
o Children aged 0 – 5 years: 25% of Main Member’s Cover up to a max of
R20,000
• Policy Members who’re pregnant and need cover for children should move to a
Product that accommodates children as soon as possible, bearing in mind the
Waiting periods. The Insurer will (in good faith), cover children born to the
Main Member/Spouse for the first 3 months from their date of birth.
• The benefit(s) of this policy will not be paid if death is directly or indirectly
caused by or attributable to:
o Acts of God, tsunami, cyclone, earthquake and/or landslide
o Divorced spouses at inception of the policy are not covered, and cover for
spouses who divorce during the term of the policy will cease immediately
on divorce.
o Influence of alcohol or drugs
o Intentional self-inflicted injury
o Nuclear explosions
o Radioactivity
o Terrorism or war (whether declared or not), acts of foreign enemies, civil
war, rebellion, revolution, insurrection, riots and civil commotion.
o Unlawful or criminal activities, or as a result of the involvement in unlawful
or criminal activity or activities of the Main Member, the Main Member’s
spouse, dependants or nominated beneficiaries.
o Wilful exposure to danger.
Succession: Cover will cease for all Policy Members on the Main Member’s death.
If a Policy Member wants to continue with the Policy they need to apply as a new
Main Member, by submitting a new Application. This will ensure that Cover
continues without new/ additional Waiting periods. Cover for all Policy Members
is subject to the Insurer to receiving the relevant Premiums.
Surrender Values: Premiums are payable for the duration of the Policy and aren’t
refundable. Cover under this policy is provided on a month-to-month basis without
reserves accumulating and therefore premiums are payable to maintain cover.
Should the Main Member wish to terminate the policy, he/she will not receive any
cash benefit and or surrender value.
Waiting Periods: The following waiting periods apply, following
Commencement of Cover:
• No Waiting Period will apply in respect of Accidental Death.
• A 6-month Waiting Period will apply to any Policy Member/s in respect of
death due to natural causes.
• A 12-month Waiting period will apply to any Policy Member/s in respect of
death due to Suicide.
• If Benefits are added/ increased at any stage for a Main member/Policy
Member, a new Waiting period will apply to the added Benefit/s.
• If an active funeral policy is replaced, the Waiting period served on the replaced
policy will be considered. However, this only applies in respect of the replaced
policy’s Cover. If the selected Cover is higher, then there’ll be a Waiting period
on the increased Cover. This only applies to Policy Members who were covered
on the replaced policy. The replacement must be proven by the Main Member
by providing a:
o replacement record of advice, if applicable;
o notice of cancellation with the previous insurer;
o 6 months’ payment history with the previous insurer for each replaced
policy.
If the Main Member can’t provide the above documents, the Policy will default
to a 6-month Waiting period.
LAPSE & REINSTATEMENT
Grace Period: A 60-day (two calendar months) grace period is allowed to pay a
missed premium once the policy is in force. If the premium is not paid within the
grace period the cover will be cancelled without further notice.
Lapse: The Policy will terminate automatically on midnight of the last day of the
Grace Period (when two consecutive premiums were missed) and cover will cease.
Reinstatement In the event that the Policy terminates due to non-payment of
premiums, the Underwriter shall in its sole discretion be entitled to issue a new
policy ("Reinstated Policy").
• If the Reinstated Policy’s Commencement Date is within 2 months from the
cancellation of the Policy, then the Underwriter shall not impose a new waiting
period in respect of the Reinstated Policy if all outstanding premiums have been
paid.
• If a waiting period under the cancelled policy had not yet expired as at the
termination date thereof ("Remaining Period"), the Remaining Period shall
apply from the commencement date of the Reinstated Policy.
• The Premium payable for the Reinstated Policy will be based on the Policy
Members’ age at date of Commencement of Cover of the Reinstated Policy.
• Reinstatement isn’t allowed at claims stage and won’t be allowed more than
once in the lifetime of the Policy.
• The Insurer reserves the right to either accept or decline reinstatement of the
Policyholder or any other Policy Member/s.
• All claims related to the Insured Event that occurred during the Grace Period
will be forfeited, if the Policy lapse. No claim so forfeited will be revived by
the Reinstated Policy and the Underwriter will have no obligation to any party
in relation to the forfeited claim.
CONSENT
Consent to Process, Disclose and Share Personal Information: We are limited
by legislation to only collect and process information that specifically relates to,
and is relevant to this Policy, and we are accountable for this information. We
undertake to keep such information confidential, secure and to maintain such
information only for as long as it is needed and/or prescribed in terms of the
applicable laws and will, at all times, comply with the applicable data protection
legislation, which includes without limitation, the Protection of Personal
Information Act, 4 of 2013.
• You authorise BACARAC and the Underwriter’s staff, representatives,
contracted third-party service providers, applicable reinsurers and
subcontractors to collect and process personal information from you or any third
party, including without limitation, an Assured Life, Beneficiary and Premium
Payer.
• By accepting the terms and conditions of this Policy, the Main Member
effectively consents to:
o enter into this policy;
o receive communication from the Insurer/Binder holder/Intermediary, and
o having his/her personal information processed in terms of the Insurer’s
Privacy Policy
• Processing of personal information includes:
o Verifying the information provided against any data source and compiling
non-personal statistical information.
o Sharing information to any affiliate, subsidiary, or reinsurer to provide
insurance services, and enable further legitimate interests, including
statistical analysis, reinsurance, and credit control.
o Sharing information to any appointed third-party service provider/s.
• This consent clause will remain in force unless the Main Member objects to the
processing of his/her personal information/data via lifepopi@kingprice.co.za.
FICA Verification: Your application needs to be verified according to FICA
regulations, accordingly acceptance of your Application is in the sole discretion of
the Underwriter’s acceptance.
CLAIMS
Fraudulent Claims: The Underwriter will not pay any fraudulent claim that is
made against this policy. The Underwriter will, at its own discretion, be entitled to
cancel this policy, and any other policy held by the Main Member or Claimant, with
immediate effect, should any fraudulent claim be made to the Underwriter’s
detriment.
Investigations: The Insurer reserves the right to investigate claims, which may
affect the claim payment turnaround time.
Notice: In the event of a claim, Bacarac must be contacted.
Outstanding Premiums: No claim will be paid if premiums or parts of premiums
are outstanding or in arrears, limited by any and all legislative requirements.
Payment of the Policy Benefits:
• Payment of the Policy Benefits will be a full and effectual discharge of the
Insurer’s liabilities.
• A claim payment (following the Main Member’s death) is directly payable to
the Beneficiary/ies.
• Claim payments for Insured Events other than the Main Member’s death, are
directly payable to the Main Member.
• The Insurer will honour the written request of a Claimant to have a claim
amount paid directly to Bacarac Group Schemes in order for Lesedi House
Funerals to render the Policy Benefit/s.
Prescription: An Insured Event should be reported and supporting documents
submitted, in writing, within 12 months. The claim will be forfeited and not
honoured if the claim isn’t submitted successfully within this period.
Repudiation: No claim will be considered (or Benefit paid out)
• if the Policy member doesn’t fall within the definitions or parameters as detailed
in these terms and conditions;
• unless documentary evidence, as determined by BACARAC and/or the
Underwriter entirely in its own discretion, has been supplied as positive
verification of the Insured Event;
• if the claim was not made in accordance with the Policy;
• where the Insured Event happened
o before Commencement of Cover,
o after cancellation of the policy,
o after cover in respect of the assured life ceased,
o after a policy has lapsed,
o or where a waiting period is applicable which has not yet expired.
If an Insured Event occurs in respect of a Main Member or any other Policy
Member outside the borders of South Africa, such claim will be subject to receipt
of the official proof of death from another country, which the Insurer may or may
not be able to verify. Payments of claims under such circumstances can therefore
not be guaranteed.

Signature

Clear

How to claim

HOW TO CLAIM
Notify us of your claim for benefits by
• notification to Bacarac Group Schemes at Lesedi House
Funerals at
o LesediHouseFunerals@Bacarac.co.za
o 086 053 7334 or 063 847 9692
o Lesedi House Funerals, Nedbank Building, 7 Ryk
Street, Welkom
• Notification to the Bacarac Group Schemes’ Claims
department at
o Claims@Bacarac.co.za
o 082 867 7000
You will be directed and assisted to prepare and submit
your claim
Submit the following documents to BACARAC at
Claims@Bacarac.co.za or to an authorised representative
of BACARAC.
• Completed and signed Claim Form
• Certified copy of the Death Certificate
• Certified copy of the Notification of Death (BI-1663)
• Signed Police Report Document (obtained from Bacarac
Group Schemes) in the event of death due to unnatural
causes
• Certified copy of the Identity Document of each of
o the Main Member, and
o the Deceased, and
o the Claimant, and
o the Beneficiary.
• Stamped bank statement of the Claimant
• Additional documents listed on the Claim Form and/or
as requested at the discretion of the Underwriter and/or
Bacarac Group Schemes, depending on the nature of the
claim.
The Underwriter shall not consider any claims for common-
law spouses or spouses married by tribal custom or under
the tenets of any religious marriage, unless they are
nominated on the application form or by way of an
amendment form as a dependant, whichever is satisfactory
the Underwriter, in its sole discretion.
In the event of a claim for a full-time student, a letter
confirming full-time study from a recognised educational
institution, together with the last academic report, must be
submitted.
For a disabled child, confirmation of the Disability Grant,
copy of Medical Application of the Main Member or
Medical Report.
The calculation of the claim benefit:
• The spouse and children aged 14[EG1] years and older
qualify for the full cover amount.
• Children from 6 years to 13 years of age qualify for 50%
of the cover amount with a maximum value determined
by legislation..
• Children younger than 6 years of age qualify for 25% of
the cover amount with a maximum value determined by
legislation..
After payment of the claim settlement amount in rand value
to Bacarac Group Schemes , who will provide the Policy
Benefit/s as laid out in this application to the claimant, the
Underwriter shall be released from all further responsibility
regarding the claim.
The underwriter reserves the right to request further
documentation and/or information as it may deem
necessary to accurately assess a claim
The underwriter will endeavour to settle the claim within
48 hours, from receipt of all claim documentation,
provided all the claim procedure criteria have been met.
Your policy is underwritten by
King Price Life Insurance Limited (“The Underwriter ”)
Reg No. 1948/029011/06
a licenced insurer and an authorised Financial Services
Provider FSP No. 47235
Block C, Menlyn Corporate Park, 175 Corobay Ave,
Pretoria, 0181
086 100 7967
LifeLegal@KingPrice.co.za
Your Policy is administered by
4D Group Solutions, an authorised Financial Services
Provider (FSP no. 14854)
Your Intermediary is
BACARAC Trading 109 Pty Ltd (“Bacarac”)
Bacarac Group Schemes
Reg No. 2008/012768/07
an authorised Financial Services Provider (FSP no. 37364)
PO Box 858, Kuilsriver, 7579
082 867 7000
Members@Bacarac.co.za
Head Office
14 Plantanus St, Kuilsriver
082 867 7000
Offices:
Pretoria, Nigel, Polokwane,
Burgersfort, Klerksdorp, Bloemfontein,
Welkom, Kuilsriver
Welkom Office
Lesedi House Funerals
Nedbank Building, 7 Ryk St, Welkom
086 053 7334
LesediHouseFunerals@Bacarac.co.za
Your Service Provider
Lesedi House Funerals
Head Office / Welkom Office
Nedbank Building, 7 Ryk St, Welkom
086 053 7334 063 847 9692
Bloemfontein Office
10341 Tsuene St, Rocklands, Bloemfontein
086 053 7334 060 290 8755
Mortuary
94B Constantia Rd, Welkom
057 355 6286
Info@LesediHouse.co.za
COMPLAINTS PROCEDURE
1. Contact and discuss your complaint with us at any of our
offices or contact us by e-mail at Compliance
@Bacarac.co.za / LesediHouseFunerals@Bacarac.co.za
or by phone at 086 053 7334 / 063 847 9692 / 082 867
7000
2. If you don’t receive a response within 20 days or isn’t
satisfied with the response from the Intermediary, a
formal complaint can be made to the Underwriter at
LifeComplaints@KingPrice.co.za
3. If the Policyholder isn’t satisfied with the Underwriter’s
response he/she may contact the National Financial
Ombudsman by phone at 086 080 0900, or WhatsApp at
066 473 0157 or by e-mail at Info@nfso.co.za, or
4. If a Policyholder isn’t satisfied with the
Intermediary/Binder holder, he/she may contact the
Ombudsman for Financial Services Providers by phone
at 012 762 5000 / 012 470 9080 or e-mail to
Info@faisombud.co.za or letter to P.O Box 74571,
Lynnwood Ridge, 0040
FEE DISCLOSURE
Up to 55% of the Policy Premium is a financial services
fee which is included in the Policy Premium for the
benefit of the Intermediary to provide for data
processing fees, policy administration fees, compliance
fees, communication fees, marketing fees and commission
related to this policy,
The Underwriter receives the value of the Policy
premium less the Financial Services Fee to underwritethis policy.

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