Please see your brochure for details on the number of dependants you can add. We require proof of registration from the relevant school, college, university or other academic institution for dependant children who are 21 or older and full-time students.
(Below the age of 75 years at entry)
You can add additional dependants to your cover. Additional extended dependants can be your biological parents, biological siblings, spouse, aunt, uncle, parents-in-law, sister-in-law, brother-in-law, step parents or grandparents. You can also add your spouse's biological siblings.
I hereby instruct my employer to deduct my monthly premium from my salary to give to Atlehang Life (FSP:51568) as per the details provided here.
Should the premium be adjusted by Atlehang Life as a result of a general increase or decrease in rate, or should I request the insurer to increase or decrease my premium for certain reasons, I confirm that the adjusted premium may be deducted from my salary, until such time as I cancel this authorisation in writing.
Debit order (Please complete your debit order instruction below)
By signing this form, you understand and agree that you are applying for funeral cover on the Master Policy held with Atlehang Life, a licensed Micro-insurer FSP:51568. Your policy is administered by Everest Funerals North West and Atlehang Life, which renders binder functions on behalf of Atlehang Life. You declare that the information you've provided in this form is accurate and true, and that Atlehang Life has the right to cancel this policy with immediate effect should they find out any of the information you've provided is untrue. You also understand that you will forfeit any premiums paid to Atlehang Life should you provide false information. You declare that your representative has explained the terms and conditions of your cover, and you understand them. Atlehang Life has the right to decline your application within 30 days of the application. If you don't receive formal communication that your application has been denied within 30 days, you may consider your membership active and binding.
Your cover will only start once Atlehang Life receives your first premium. Atlehang Life reserves the right to decline your application within 30 days of you applying for cover. If you cancel your policy within 30 days of Atlehang Life confirming your policy number and policy start date, Atlehang Life will refund your premium (excluding the administration fee).
Please print your name as a form of your signature
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