Dimeva Burial Society

Applicant Details

Title: Full Names: Surname: Date of Birth: Identity No: Email: Cell Phone No: Physical Address: Street Address: City: Province: Postal Code:

Benefits / Products Selection

I hereby apply for membership of Dimeva Burial Society (“hereinafter referred to as Dimeva”). I also apply for the following benefits/products (Please tick and initial next to your selection):

Dimeva Single Member

Dimeva Immediate Members

Dependents Details

#	Full Names and Surname	Relationship	ID No.	Date of Birth
1
2
3
4
5
6
7
8
9

Beneficiary Nomination

I hereby nominate the following beneficiary to receive any benefits due to be paid from the scheme in the event of my death.

Full Names and Surname: Identity No: Relationship:

Summary of Terms and Conditions

I confirm that I am aware of, I agree with, and I accept the terms and conditions and the terms and conditions of the constitution and resolutions of Dimeva and the terms and conditions of the insurer/underwriter.

I authorize Dimeva to insure myself and my dependents for benefits applied for with any insurer of its choice. I am aware that the waiting period is 6 (six) months and the waiting period for suicide death is 12 (twelve) months. No waiting period shall apply for accidental death if first premium has been received by insurers.

Protection of Personal Information Declaration

I acknowledge that I have read and understood Dimeva’s Protection of Personal Information Declaration and consent to the collection, processing, and use of my personal information for the purposes of concluding and administering funeral policy and/or burial society services.

I give my consent to receive direct marketing from Dimeva: Yes No