Application Forms

This is your application form for funeral cover on the Master Policy held by Everest Funerals.

Please fill in all the relevant sections truthfully, in full, and make sure your answers are clear. You must provide Everest Funerals with your identity document or driver’s licence and those of all the dependants you would like to add to your membership when applying.

Office use only

Your funeral cover choice

Your funeral cover choice

Applicant Details



Dependants

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.

Extended Family Dependants

(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.

Payment Method

Payment method

Please fll in the relevant section below Stop order (persal code: 0321)

I hereby instruct my employer to deduct my monthly premium from my salary to give to BrightRock Life Limited (FSP 11643) as per the details provided here

Should the premium be adjusted by BrightRock Life Limited as a result of general increase or decrease in rate or should I request the insurer to increase or decrease my premium for certain reasons, I confrm 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)

Account type
Preferred debit order day?

Section F: Policy owner declaration and signature

By signing this form, you understand and agree that you are applying for funeral cover on the Master Policy held with BrightRock Life Limited. Your policy is administered by Everest Funerals North West and BrightRock which renders binder functions on behalf of BrightRock Life Limited. You declare that the information you've provided in this form is accurate and true and that BrightRock 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 BrightRock Life Limited should you provide false information. You declare that your representative has explained the terms and conditions of your cover and you understand them. BrightRock 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 BrightRock receives your frst premium. BrightRock reserves the right to decline your application within 30 days of you applying for cover. If you cancel your policy within 30 days of BrightRock confrming your policy number and policy start date BrightRock will refund your premium (excluding administration fee).

Please print your name as a form of your signature

Office use only

Your funeral cover choice

Your funeral cover choice

Applicant Details



Dependants

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.

Extended Family Dependants

(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.

Payment Method

Payment method

Please fll in the relevant section below Stop order (persal code: 0321)

I hereby instruct my employer to deduct my monthly premium from my salary to give to BrightRock Life Limited (FSP 11643) as per the details provided here

Should the premium be adjusted by BrightRock Life Limited as a result of general increase or decrease in rate or should I request the insurer to increase or decrease my premium for certain reasons, I confrm 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)

Account type
Preferred debit order day?

Section F: Policy owner declaration and signature

By signing this form, you understand and agree that you are applying for funeral cover on the Master Policy held with BrightRock Life Limited. Your policy is administered by Everest Funerals North West and BrightRock which renders binder functions on behalf of BrightRock Life Limited. You declare that the information you've provided in this form is accurate and true and that BrightRock 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 BrightRock Life Limited should you provide false information. You declare that your representative has explained the terms and conditions of your cover and you understand them. BrightRock 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 BrightRock receives your frst premium. BrightRock reserves the right to decline your application within 30 days of you applying for cover. If you cancel your policy within 30 days of BrightRock confrming your policy number and policy start date BrightRock will refund your premium (excluding administration fee).

Please print your name as a form of your signature

Always by your side.