Official Membership Application

Apply for Dibas Policy Cover

Authorized Financial Service Provider (FSP NO. 51530). Insured by Anayasure (FSP 52695) & Clientele Life (FSP 15268). Joining Fee: R200.00.

1Select Your Plan & Tier

Funeral Plan

Coverage Tier

2Personal Details of Main Member

Title

Full Names

Surname

South African ID Number

Marital Status

Cell Number

Physical Address

Email Address

3Personal Details of Spouse (If Applicable)

Spouse Full Names

Spouse Surname

Spouse ID Number

4Dependants Covered (Max 9)

Tier 2 covers up to 9 dependants (under 75 years).

Dependant 1 Name

Gender

ID / DOB

Declaration & Policy Terms

I hereby declare that all information supplied herein is true and accurate. I understand that misrepresentation may lead to policy cancellation. I acknowledge the 6-month probation period and monthly payment due date before the 10th.

I agree to the declaration terms and conditions of Dibas Funeral Services.