Triarc (PTY) LTD
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SECTION 1

POLICY HOLDER DETAILS

SECTION 2

FAMILY COVER

SPOUSE

CHILDREN

Maximum entry age of 21, a maximum of 5 children can be added.

PARENTS AND PARENTS IN LAW

Maximum entry age of 75, a maximum of 4 parents or parents in law are can be added.

EXTENDED FAMILY MEMBERS

Maximum entry age of 65, a maximum of 4 extended family members can be added.

SECTION 3

PLAN SELECTION, SINGLE MEMBER

Enter the premium from the table above next to the age of the principle member and for the Plan you selected. Example, the premium for a 30 year old is R17.75 for Plan 2.

PLAN SELECTION, FAMILY

 
Select the Plan you want from the table above.

Enter the premium from the table above next to the age of the principle member and for the Plan you selected. Example, the premium for a 30 year old is R47.10 for Plan 2.
Enter the premium from the table above for the Spouse premium waiver, example, if the premium for a 30 year old is R47.10 then the premium waiver will be 47.10 x 0.01479811 = R0.61

PARENTS AND PARENTS IN LAW SELECTION

 

 

 

 

From the table above, add the premiums for all the additional family members you want to next to their age and for the Plan you selected for the principle member. Example, the premium for a parent that is 60 years old is R54.11 for Plan 2.

EXTENDED FAMILY SELECTION

 

From the table above, add the premiums for all the additional family members you want to next to their age and for the Plan you selected for the principle member. Example, the premium for a parent that is 60 years old is R54.11 for Plan 2.

OPTIONAL BENEFITS SELECTION

 
Enter the premium for all the Optional Benefits you selected.

TOTAL PREMIUM AND START DATE

Add all the premiums above and enter the total premium that you will be paying.

SECTION 4

BENEFICIARY NOMINATION

Beneficiary to whom the money will be paid on the death of the Policyholder. Please complete the details of the beneficiary you nominate. If any of the other Insured Life’s die on this policy, you will be the beneficiary and we will pay the benefits to you. If you do not nominate a beneficiary to receive the Money in the event of your death, we will pay the money from your policy to your estate.
A secondary nominated beneficiary is advisable in the case that the Policyholder and primary beneficiary dies together.

SECTION 6

PREMIUM PAYER DETAILS

BANKING DETAILS

It is important that you provide us with the correct banking details from for collection of the premium. Triarc (Pty) LTD will not be legally responsible if you give us the incorrect banking details. You must inform us if your banking details change.

I/we, the undersigned, confirm that the account information I have provided is an account in my name. This signed Authority and Mandate refers to our contract as dated on signature hereof.
I/We hereby authorise Triarc to issue and deliver payment instructions to the Bank for collection against my/our above-mentioned Bank account at my/our above-mentioned Bank(or any other bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instruction will never exceed my/our obligations as agreed in our contract/agreement and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of not less than 20 ordinary working days, and sent to you in writing.
The payment day may be aligned to an earlier salary in December if agreed by you and Triarc.
The individual payment instructions so authorised to be issued must be issued and delivered and will continue monthly from the start date as indicated above.
In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the very next business day. Furthermore, if there are insufficient funds in my account to meet the obligation, you are entitled to track my account and represent the instruction for payment as soon as sufficient funds are available in my account.
I/we understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks. I also understand that details of each withdrawal will be printed on my bank statement. Such must contain a number,
which must be included in the said payment instruction and if provided to me should enable me to identify the Agreement.
I/we acknowledge that all payment instructions issued by you shall be treated by me/our above-mentioned bank as if the instructions had been issued by me/us personally. I/we agree that although this Authority and Mandate may be cancelled me/us, such cancellation will not cancel the Agreement. I/we shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you. I/we acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.
We will confirm your Authority and Mandate in writing prior to processing the debit order against your account.
To verify the banking details, Triarc may request a bank letter, or a copy of a bank statement.

I accept the terms and conditions.

About Us

TRIARC is an authorised financial services provider FSP45009. TRIARC insurance products underwritten by Guardrisk Life FSP76. Council of Medical Scheme
Number ORG 4040.

About us

TRIARC is an authorised financial services provider FSP45009. Council of Medical Scheme Number ORG 4040.

Contacts

087 231 0222
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