Rodel4U legacy online application

Main Member Information:
Main Member Detail:*
Title: First Name: Surname:
Postal Address:*
Postal Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
ID Number/Passport Number:*
Date of Birth:*
DD dash MM dash YYYY
Cell Number:*
Alternative number:
Employer:
Work Number:
Email Address:
Nationality:*
- RSA
Language:*
Marital Status:*
- Single
- Married
- Divorced
- Widowed
Preferred Correspondence:*
- Email
- Post
Please proceed to the next section.

Banking Details of the person who will pay for the policy. By inserting this detail you are authorizing Rodel to debit the account for the premium selected.
Payment Method:
- Debit order
Kindly note that if the premium will be paid by a 3rd party, we reserve the right to verify the authority to deduct premiums from the account holder.
Account Holder Name:
Title First Last
Account Holder ID:
Account Holder Cell Number:
Account Holder Postal Address:
Postal Address Line 2 City State / Province / Region ZIP / Postal Code
Bank Name:
Account Number:
Type of Account:
- Cheque
- Savings
- Transmission
Branch Code:
First Deduction Date:
DD dash MM dash YYYY

The Date you want the the monthly debit order to go off.
Salary Date:
DD dash MM dash YYYY

The day on which you get paid.
I hereby confirm the details given above are true and correct, and understand the application will be subject to standard terms and conditions as amended from time to time*
- Yes, The bank details are correct
- Call me for Bank details.
Rodel Agents are ready and waiting to contact you if you would prefer not to fill in your banking details online, or do not have them on hand during your application process. All calls are recorded for our mutual protection.
Premium Payer Signature:*
Please proceed to the next section.

Particulars of Insured Dependants
Kindly note that only direct biological and legally adopted children will be covered, up until the age of 18, or under the age of 25 and a full time student at an Educational Institution. By law we may not provide policy benefits of more than R20 000 to an unborn, or of a minor dependent before he or she attains the age of six years, or more than R50 000 if the minor is older than 6 years but not 14 years yet.
Please note, you have selected the Individual Cover option. Should you wish to add dependents, you will need to go back to the beginning and select the Family Cover option and the relevant Premium you wish to pay.
Spouse's Name & Surname:
First name Surname
Spouse's ID Number/DOB:
Spouse's Cell Number:
Child 1 Name & Surname:
First name Surname
Child 1 ID Number/DOB:
Child 2 Name & Surname:
First name Surname
Child 2 ID Number/DOB:
Child 3 Name & Surname:
First name Surname
Child 3 ID Number/DOB:
Child 4 Name & Surname:
First name Surname
Child 4 ID Number/DOB:
Child 5 Name & Surname:
First name Surname
Child 5 ID Number/DOB:
Please proceed to the next section.