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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 Certicate will cease.


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


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.


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
• 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


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.








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

52 18th AVENUE
Tel no: 021 949 6021
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

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

Bergroos St Brackenfell. 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. Should my account fall in arrears. OF PREMIUM PAYER EMAIL OF PREMIUM PAYER DATE OF BIRTH SA ID.For more info SMS PEACE to 40439 | info@peaceplan.  3. You may declare a common law spouse or that of a traditional marriage.  I authorise AUI to increase my monthly premium to cover the arrears within the contract period. SPOUSE’S SURNAME SPOUSE’S 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. All such withdrawals from my Bank account for this purpose shall be treated as though they had been signed by me personally.Protea Village. I agree to pay any and all bank charges that relate to this debit order including.  5. Receipt of this instruction by AUI shall be regarded as receipt thereof by my Bank. without derogating from the general hereof. FSP 8447 and administrated by Zinmar Corporate Consultants FSP 14286 My Peace Plan is a juristic representative of ZINMAR CORPORATE CONSULTANTS 3 Stonehill Estate. FSP 14286 My Peace Plan is a juristic representative of ZINMAR CORPORATE CONSULTANTS  EXTENDED FAMILY MEMBERS (IN ZIMBABWE ONLY) Agent : Individual Premium . NAME: SA ID OR PASSPORT NO.  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. 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.  8.  2. all lodgement. RELATIONSHIP RATE SECTION 5 : Nominated Beneficiary Details: ( Beneficiary must be older than 16 years of age ) SURNAME FIRST NAME TEL NO. failure and other costs that AUI may incur. Capetown | 209 Bellairs Drive Northriding Johannesburg SECTION 1 : To be completed by all applicants. 64 years and younger APPLICANT’S DETAILS: SURNAME FIRST NAMES TEL NO. CELL NO. OR PASSPORT NO COUNTRY OF ORIGIN MARITAL STATUS SEX POSTAL ADDRESS SUBURB TOWN PROVINCE POSTAL CODE SECTION 2 : Details of the Applicant’s spouse to be completed here.  4. DATE: Benefits Option Cover (Select 1) (Select 1) | 021 013 0111 Capetown | 011 079 1664 Johannesburg Underwritten by African Unity Insurance Limited.  6.