Quote Form – NSBSA

User Quotation Form

Step 1 of 3

Main Members Personal Detail
Name*
Title First Name Last Name
Martial Status*
Identity Number*
Date of Birth*
Date Format: DD dash MM dash YYYY
Gender*
Email*
Contact Tell (Work)*
Cell Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Scheme*
Cover Amount*
Cover Amount*
Cover Amount*
Cover Amount*
Age*
Premium Payable: R69
Premium Payable: R78
Premium Payable: R87
Premium Payable: R96
Premium Payable: R93
Premium Payable: R127
Premium Payable: R161
Premium Payable: R195
Premium Payable: R102
Premium Payable: R144
Premium Payable: R195
Premium Payable: R229
Premium Payable: R85
Premium Payable: R98
Premium Payable: R116
Premium Payable: R130
Premium Payable: R131
Premium Payable: R193
Premium Payable: R255
Premium Payable: R316
Premium Payable: R99
Premium Payable: R129
Premium Payable: R156
Premium Payable: R182
Premium Payable: R123
Premium Payable: R1179
Premium Payable: R231
Premium Payable: R282
Premium Payable: R141
Premium Payable: R213
Premium Payable: R282
Premium Payable: R351
Premium Payable: R166
Premium Payable: R263
Premium Payable: R356
Premium Payable: R450
Premium Payable: R127
Premium Payable: R179
Premium Payable: R235
Premium Payable: R287
Premium Payable: R153
Premium Payable: R237
Premium Payable: R315
Premium Payable: R394
Premium Payable: R153
Premium Payable: R271
Premium Payable: R365
Premium Payable: R462
Premium Payable: R195
Premium Payable: R321
Premium Payable: R441
Premium Payable: R561
Beneficiary Appointment
Beneficiary Name*
First
Beneficiary Name*
Last
Beneficiary ID Number*

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Family Members Covered
Member 1
Name
First Last
ID Number
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Relation
Member 2
Name
First Last
ID Number
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Relation
Member 3
Name
First Last
ID Number
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Relation
Member 4
Name
First Last
ID Number
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Relation
Member 5
Name
First Last
ID Number
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Relation
Member 6
Name
First Last
ID Number
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Relation
Member 7
Name
First Last
ID Number
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Relation
Member 8
Name
First Last
ID Number
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Relation
Member 9
Name
First Last
ID Number
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Relation

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PAYMENT INSTRUCTION
Payment Frequency
Frequency Plan*
Day of Payment*
DEDUCTION
Date of First Deduction*
Date Format: DD dash MM dash YYYY
Cover Amount
Your Selected Scheme Amount: R69
Cover Amount
Your Selected Scheme Amount: R79.15
Cover Amount
Your Selected Scheme Amount: R98.30
Cover Amount
Your Selected Scheme Amount: R117.45
Cover Amount
Your Selected Scheme Amount: R136.59
Cover Amount
Your Selected Scheme Amount: R96.37
Cover Amount
Your Selected Scheme Amount: R132.75
Cover Amount
Your Selected Scheme Amount: R169.12
Cover Amount
Your Selected Scheme Amount: R205.50
Cover Amount
Your Selected Scheme Amount: R82.42
Cover Amount
Your Selected Scheme Amount: R104.83
Cover Amount
Your Selected Scheme Amount: R127.25
Cover Amount
Your Selected Scheme Amount: R149.67
Cover Amount
Your Selected Scheme Amount: R88.82
Cover Amount
Your Selected Scheme Amount: R117.64
Cover Amount
Your Selected Scheme Amount: R146.46
Cover Amount
Your Selected Scheme Amount: R163.76
Cover Amount
Your Selected Scheme Amount: R95.47
Cover Amount
Your Selected Scheme Amount: R130.94
Cover Amount
Your Selected Scheme Amount: R166.41
Cover Amount
Your Selected Scheme Amount: R199.76
Cover Amount
Your Selected Scheme Amount: R114.05
Cover Amount
Your Selected Scheme Amount: R168.10
Cover Amount
Your Selected Scheme Amount: R222.16
Cover Amount
Your Selected Scheme Amount: R276.21
Cover Amount
Your Selected Scheme Amount: R89
Cover Amount
Your Selected Scheme Amount: R119
Cover Amount
Your Selected Scheme Amount: R148
Cover Amount
Your Selected Scheme Amount: R177
Cover Amount
Your Selected Scheme Amount: R97
Cover Amount
Your Selected Scheme Amount: R134
Cover Amount
Your Selected Scheme Amount: R170
Cover Amount
Your Selected Scheme Amount: R198
Cover Amount
Your Selected Scheme Amount: R112.75
Cover Amount
Your Selected Scheme Amount: R165.49
Cover Amount
Your Selected Scheme Amount: R202.41
Cover Amount
Your Selected Scheme Amount: R257.27
Cover Amount
Your Selected Scheme Amount: R143.38
Cover Amount
Your Selected Scheme Amount: R226.76
Cover Amount
Your Selected Scheme Amount: R310.15
Cover Amount
Your Selected Scheme Amount: R393.53
Once-Off Payment*
- R150 admin fee payable with the 1st payment only!
BANK DETAILS
Name of Bank*
Name of Branch
Account Number*
Branch Code
and according to the agreement, If, however, the date of the payment Falls on a non-processing day(weekend or public holiday), I agree that the payment instruction may be debited against my account on the following business day.
Declaration*
“I, the undersigned, request the Body of Stokvel Investments (Pty) Ltd to arrange with my bank to collect, by means of the debit order system, the payments in terms of the stipulations of the contract and payments in arrears (as they may be amended from time to time/where applicable/where so requested) of the above-mentioned against my account.”
Today's Date*
Date Format: MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

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User Quotation Form

Step 1 of 3

Main Members Personal Detail

Beneficiary Appointment

Family Members Covered

Member 1

Member 2

Member 3

Member 4

Member 5

Member 6

Member 7

Member 8

Member 9

PAYMENT INSTRUCTION

Payment Frequency

DEDUCTION

BANK DETAILS

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