ACCOUNT BALANCE INSURANCE

Account Balance Insurance Including Retrenchment, Death, Disability and Serious Illness Insurance.

Before you complete the application form online, please ensure that you have read the Account Balance Protection Including Retrenchment, Death, Disability and Serious Illness Insurance Terms and Conditions and are aware of the monthly premium payable on this policy.

INSURED DETAILS
Truworths account number *
Title *
First name (or name known as) *
Surname *
Identity number *
Date of Birth *
Marital status *
Postal / Physical address *
Suburb
City *
Code *
Fill in at least one contact number **
Home telephone number **
Work telephone number **
Cellphone number **
Email address *

ACCOUNT HOLDER COVER ONLY:
For 35c per R100 of the outstanding balance on my account, I want my account balance to be settled up to R5,000 should I be retrenched, die, am disabled or suffer a serious illness.

Partner Cover only:
For 35c per R100 of the outstanding balance on my account, I want my account balance to be settled up to R5,000 should my partner be retrenched, die, become disabled or suffer a serious illness.

Joint Cover only:
For 70c per R100 of the outstanding balance on my account, I want my account balance to be settled up to R7,500 should I or my partner be retrenched, die, become disabled or suffer a serious illness.

Type of cover required *

For Partner or Joint Cover, please supply your partner's details below

PARTNER DETAILS
Title **
First name **
Surname **
Identity number **
Hollard

* I the undersigned, hereby declare that I have read and completed this application form and acknowledge and understand the contents thereof. I confirm that I have signed the declaration of my own free will and regard it as binding. I further acknowledge that Truworths being the intermediary has disclosed and confirmed the appropriate information contained in this document regarding the insurance policy underwritten by the Hollard Life Assurance Company Limited, which I have read and understand. I hereby accept responsibility to pay my monthly instalments on time. I understand that I am not forced to take this particular policy, and that I have freedom to choose any financial product, besides this one. to cover any debt I may have with Truworths. I understand that I am entitled to review this insurance cover within 30 (thirty) days of this application. Should I elect to cancel this policy within this period allowed. I will be entitled to 100% money back insurance premium from Truworths provided I have not claimed under the policy concerned.

* I agree to these terms and conditions

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