Scheme No Peace0001

Principal Member

The person who is responsible for the payment of the monthly premiums under this Scheme and upon whose death all insured cover on his
policy Certicate will cease.

Beneciary

The person fully described in this policy who has been elected by the Principal Member to receive the Benets or Direct the usage of the
benets claimed as a result of the death of the Principal Member.

Cancellation

The Principal Member, as well as My Peace Plan reserves the right to cancel this policy at any time after giving the other party one(1) calendar
months written notice of such intentions. The date of cancellation will take effect from the date of service on the recipient's domicilium.

REVISION OF TERMS AND CONDITIONS

My Peace Plan reserves the right to amend, revoke, vary or alter any of the terms and conditions of this policy provided that My Peace Plan
shall give the Principal Member at least 30 (thirty) calendar days written notice of such revision.
This is a Voluntary Scheme and premiums are payable in advance on or before the 7th of each month.
Main members who are 18 years or older, to a maximum of 64 years old may participate in the scheme
No restrictions are placed on the size of a family but the insured lives will be limited to those declared on the application form
Customary or common law spouses who are not legally married but are living together as a family can still enjoy family benefits provided that
all the relevant particulars are declared on the application form.
Unmarried children under the age of 21 are covered. Cover is extended up to, but not including the age 26 if the child is an unmarried full
time student. Cover for physically or mentally challenged children is subject to a six (6) calendar month waiting period as stipulated in the
Master Policy.
Cover for all members selecting R10 000 and R15 000 covers are subject to a six (6) calendar month waiting period
Cover for all members selecting R20 000 and R30 000 covers are subject to a twelve (12) calendar month waiting period
Death as a result of suicide is subjected to a 24 months waiting period.
Immediate cover is granted for accidental death after the rst Premium is received by the Underwriter.
Cover under the scheme will cease in respect of a particular member when premiums are not paid on time and received by African Unity
Insurance.
If a members' cover should cease and the member applies to re-join the scheme at a later stage, the same conditions as for new
membership will apply.
Cover under the scheme is provided for on a month-to-month basis. No reserves are built up under the scheme, therefore premiums are
payable lifelong and there are no surrender values when cover ceases
Premiums under the scheme are not guaranteed and can be adjusted by the insurer at any stage.
If a member increases his/her cover under the scheme, the increased cover amount will be subject to the relevant waiting period of 6
Months, before the full cover commences.
Membership under the scheme can only commence on the 1st day of a month.
If application to the scheme falls within the middle of a month, membership to the scheme will only commence on the 1st day of the
new month.
Application for membership is restricted to a maximum entry age of 64 years for the main members and 79 years for any extended family
member at commencement.
Only claims submitted within six (6) months of the date of the death will be considered for payment.
No claim will be honoured if premiums are in arrears or short paid.
Claims for common-law spouses NOT declared on the initial application form will NOT be considered for payment in the event of death
(Traditional marriages Lobola included).
NO claims in respect of grandchildren or foster children will be considered, unless proof of legal adoption has been supplied or if the child is
registered as an extended member.
A ten (10%) administration fees of the complete cover amount will be charged on all claims.

Cooling off Period

The Applicant shall have the option to cancel this Policy within a thirty (30) day period effective from the date of receipt of the rst monthly
premium

IMPORTANT WARNING

The Products or Transactions chosen by the applicant are deemed to meet his/her needs and requirements. To this end, it is proposed that the
Applicant engages the Intermediary or insurer with regard to the impact of the proposed transaction on his/her nances, other insurance and
insurance Policies or broader investment portfolio. The Applicant is advised to complete and sign all requisite forms after ensuring that he/she
understands the content thereof. The Applicant is invited to request information, of any nature whatsoever, whether verbal or written, relative to
this Policy. Any concerns regarding the product sold may be addressed to either the long term insurance Ombudsman or the Registrar of Long
term Insurance, whose details are set out below, if the Applicant has concerns regarding the products sold and/or advice given to him.

NAME:

SIGNATURE OF APPLICANT:

DATE:

DETAILS OF THE UNDERWRITER

DETAILS OF THE FINANCIAL SERVICES

PROVIDER

DETAILS OF THE OMBUDSMAN

DETAILS OF FINANCIAL
SERVICES BOARD

ZINMAR CORPORATE CONSULTANTS

appoints: AFRICAN UNITY INSURANCE
as the UNDERWRITER of their Policy
the My Peace Plan Group Scheme
With offices at: Riesling House, Dorp
Street, Vineyard Office Estate, Bellville 7530
Tel no: 021-913 9240
Email: info@africanunity.co.za

ZINMAR CORPORATE CONSULTANTS

52 18th AVENUE
BOSTON, BELLVILLE, 7535
Tel no: 021 949 6021
Email: Zinmar@new.co.za
Authorised Financial Services Provider
FSP 14286

Ombudsman for long term Insurance

Private Bag X45, Claremont, 7735
Tel no: 021-657 5000
Fax no: 021-674 0951
www.ombud.co.za

Financial Services
Provider
P.O. Box 35655, Menlo
Park, 0102
Tel no: 012-428 8000
Fax no: 012-347 0221
www.fsb.co.za

For more info SMS PEACE to 40439 | info@peaceplan.co.za | 021 013 0111 Capetown | 011 079 1664 Johannesburg
Underwritten by African Unity Insurance Limited, FSP 8447 and administrated by Zinmar Corporate Consultants FSP 14286
My Peace Plan is a juristic representative of ZINMAR CORPORATE CONSULTANTS
3 Stonehill Estate,Protea Village, Bergroos St Brackenfell, Capetown | 209 Bellairs Drive Northriding Johannesburg

SECTION 1 : To be completed by all applicants, 64 years and younger

APPLICANTS DETAILS:
SURNAME FIRST NAMES
TEL NO. CELL NO. OF PREMIUM PAYER
EMAIL OF PREMIUM PAYER
DATE OF BIRTH

SA ID, OR PASSPORT NO

COUNTRY OF ORIGIN

MARITAL STATUS

SEX

POSTAL ADDRESS
SUBURB

TOWN

PROVINCE

POSTAL CODE

SECTION 2 : Details of the Applicants spouse to be completed here. You may declare a common law spouse or that of a traditional marriage.
SPOUSES SURNAME

SPOUSES FIRST NAME

HUSBAND/WIFE

DATE OF BIRTH

SA ID OR PASSPORT NO

SECTION 3 : Dependents under the age of 21

SURNAME OF CHILD

FIRST NAME OF CHILD

DATE OF BIRTH

SA ID NO OR PASSPORT NO

SECTION 4 : Details of extended family members 79 years and younger

SURNAME

FIRST NAME

DATE OF BIRTH

SA ID OR PASSPORT NO.

RELATIONSHIP

RATE

SECTION 5 : Nominated Beneficiary Details: ( Beneficiary must be older than 16 years of age )
SURNAME

FIRST NAME

TEL NO.

NAME:

SA ID OR PASSPORT NO.

RELATIONSHIP

SIGNATURE OF APPLICANT:

DATE:

SECTION 6 : DEBIT ORDER INSTRUCTIONS

Please attach a copy of the Applicants Bank Statements/Cheque to ensure correct bank details

BANK

BRANCH

ACCOUNT TYPE
CHEQ

NAME:

SAVINGS

ACCOUNT NAME

ACCOUNT NUMBER

SIGNATURE OF PAYER:

I hereby authorise African Unity Insurance (AUI) to draw against my account with the above mentioned
bank (or any other bank or branch to which I may transfer my account) the amount necessary for
payment of the monthly Premium due in respect of this Funeral Insurance Policy. All such withdrawals
from my Bank account for this purpose shall be treated as though they had been signed by me
personally. Should my account fall in arrears, I authorise AUI to increase my monthly premium to cover
the arrears within the contract period. I understand that the withdrawal hereby authorised will be
processed by computer through a system known as Bankserve or any other electronic means and I
understand that details of which will be printed on my bank statement or an accompanying voucher. I
agree to pay any and all bank charges that relate to this debit order including, without derogating from
the general hereof, all lodgement, failure and other costs that AUI may incur. Receipt of this instruction
by AUI shall be regarded as receipt thereof by my Bank.

DATE:

Benefits Option

Cover

(Select 1)

(Select 1)

1.

2.

3.

4.

5.

6.

7.

8.

Family

(IN SA ONLY)

ADDITIONAL BURIAL COVER

TOTAL

Powered by My Peace Plan

Underwritten by African Unity FSP 8447 and administered
By Zinmar Corporate Consultants, FSP 14286
My Peace Plan is a juristic representative of
ZINMAR CORPORATE CONSULTANTS

EXTENDED FAMILY MEMBERS

(IN ZIMBABWE ONLY)

Agent :

Individual

Premium