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01
Member
Details
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additional
members
03
Beneficiary
details
04
Payer
details
05
Policy
confirmation

Please confirm you would like to cancel the sale. Please note this action is irreversible.


Yes
No
Discounted Staff Premium:

I hereby authorise the deduction of contributions from my salary while I continue to be employed by Clientèle.

Please Note: Your 50% discount is applicable only while you remain a Clientèle employee.


Yes
INTRODUCTION

Thank you for choosing to buy your Clientèle plan online. We have made it easier for you to get cover at your convenience. In order to complete the form please have your ID number, your income before tax and bank details available. You must be the account holder of the bank account that will be debited.

You can choose the type of plan that will suit your needs based on the list below:

HEALTH EVENT LIFE PLAN (H.E.L.P) PLAN'S OPTIONS: SELECT
1. Standard H.E.L.P Plan – Plans start from R525 per month. Up to R250,000 annual cover; Up to R2,500 Daily Cash benefit. Select
2. Ultimate H.E.L.P Plan - Plans start from R573 per month. Includes Premium Pay Back Benefit. Up to R250,000 annual cover; Up to R2,500 Daily Cash benefit. Selected

Once you have completed all the steps and purchased your Ultimate H.E.L.P Plan your Policy documents will be emailed to you, which will have all the details of your new Policy. Simply DebiCheck and pay all of your premiums and get Clientèle Royalty for FREE.

Clientèle Royalty is a FREE loyalty programme that offers policyholders access to monthly savings & discounts on Groceries, Movies, Travel, Fashion, Entertainment, Fast Food, Education vouchers and so much more! You also stand a chance to Spin & Win for your share of R10 million in prizes.* PLUS December is on us – Simply DebiCheck and pay all of your monthly premiums & Clientèle could pay your December premium for you!* Clientèle Royalty, rewarding loyalty!

*Terms and Conditions Apply.


Please enter your email address in order to start the application or to continue with an existing application.


This e-mail address will be used for all future communications.

By submitting your details you consent to Clientèle processing and retaining your personal information in line with our Privacy Policy which is available on: www.clientele.co.za.

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Are you sure you wish to remove this child? This cannot be undone.


OK
CANCEL

Are you sure you wish to remove this extended member? This cannot be undone.


OK
CANCEL

Are you sure you wish to remove this Beneficiary? Beneficiary allocation percentage must total 100% to continue.


OK
CANCEL

You are . Beneficiary allocation percentage must total 100% to continue.


Our System indicates that you already have a sale in progress would you like to continue or start a new sale?


new sale
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Our System indicates that you already have a sale in progress for would you like to continue with that product sale or start a new sale?


new sale
Continue

Death benefits for children are subject to restrictions and will be paid out as per below table.


Age at claim event Benefit (irrespective of Benefit Amount)
Below the age of 2 R2,500
2 – 5 R5,000
6 – 13 R10,000
14 – 18 100% of the Total Funeral Benefit

Children up to the age of 21 years may remain on the policy provided they are full time students, attending a registered institution (proof of registration will be required at claims stage.)

A DPIP (domestic prominent influential person) is an individual who holds, including in an acting position for a period exceeding six months, or has held at any time in the preceding 12 months in South Africa a prominent public function including the following:

The President or Deputy President.
A Government Minister or Deputy Minister.
The Premier of a Province.
A Member of the Executive Council of a Province.
The Head, Accounting Officer or Chief Financial Officer of a National or Provincial Department or Government Component.
The Chairperson of a Controlling Body, the Chief Executive Officer, or a natural person who is the Accounting Authority, the Chief Financial Officer or the Chief Investment Officer of a Public Entity listed in Schedule 2 or 3 to the Public Finance Management Act.
An Executive Mayor of a Municipality.
The Municipal Manager of a Municipality.
The Chief Financial Officer of a Municipality.
The Chairperson of the Controlling Body, Chief Executive Officer, Chief Financial Officer or Chief Investment Officer of a Municipal Entity as defined in Section 1 of the Local Government: Municipal Systems Act.
A Constitutional Court Judge or any other Judge.
A Leader of a Political Party.
A Member of a Royal Family or Senior Traditional Leader.
An ambassador or high commissioner or other senior representative of a foreign government based in the Republic of South Africa
An officer of the South African National Defence Force above the rank of major-general
The position of head, or other executive directly accountable to that head, of an international organisation based in the Republic of South Africa

An FPPO (foreign prominent public official) is an individual who holds, or has held at any time in the preceding 12 months, in any foreign country a prominent public function including that of a:

Head of State or Head of a Country or Government.
Government Minister or equivalent Senior Political or Leader of a Political Party.
Member of a Foreign Royal Family.
Senior Judicial Official.
Senior Executive of a State-owned Corporation.
High-ranking Member of the Military.

Annual cover for children is subject to restrictions and will be paid out as per below table.


Age at claim event Percentage of benefit
Up to the age of 4 50%
4-18 100%

In addition Cover for Children under 6 years of age is limited to R10,000 per annum and Cover for Children between 6 and 14 years of age is limited to R30,000 per annum.

Children up to the age of 21 years may remain on the policy provided they are full time students, attending a registered institution (proof of registration will be required at claims stage.)

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Member Details
* Mandatory Fields



This e-mail address will be used for all future communications.

FICA Declaration
In the past year, have you, or anyone on this policy held any public position including acting as any government official or politically related position? * ?

A DPIP (domestic prominent influential person) is an individual who holds, including in an acting position for a period exceeding six months, or has held at any time in the preceding 12 months in South Africa a prominent public function including the following:

The President or Deputy President.
A Government Minister or Deputy Minister.
The Premier of a Province.
A Member of the Executive Council of a Province.
The Head, Accounting Officer or Chief Financial Officer of a National or Provincial Department or Government Component.
The Chairperson of a Controlling Body, the Chief Executive Officer, or a natural person who is the Accounting Authority, the Chief Financial Officer or the Chief Investment Officer of a Public Entity listed in Schedule 2 or 3 to the Public Finance Management Act.
An Executive Mayor of a Municipality.
The Municipal Manager of a Municipality.
The Chief Financial Officer of a Municipality.
The Chairperson of the Controlling Body, Chief Executive Officer, Chief Financial Officer or Chief Investment Officer of a Municipal Entity as defined in Section 1 of the Local Government: Municipal Systems Act.
A Constitutional Court Judge or any other Judge.
A Leader of a Political Party.
A Member of a Royal Family or Senior Traditional Leader.
An ambassador or high commissioner or other senior representative of a foreign government based in the Republic of South Africa
An officer of the South African National Defence Force above the rank of major-general
The position of head, or other executive directly accountable to that head, of an international organisation based in the Republic of South Africa

In the past 12 months, have you, or anyone on this policy held a position in a prominent public function in a foreign country? * ?

An FPPO (foreign prominent public official) is an individual who holds, or has held at any time in the preceding 12 months, in any foreign country a prominent public function including that of a:

Head of State or Head of a Country or Government.
Government Minister or equivalent Senior Political or Leader of a Political Party.
Member of a Foreign Royal Family.
Senior Judicial Official.
Senior Executive of a State-owned Corporation.
High-ranking Member of the Military.
How much cover do you want?

By submitting your details you consent to Clientèle processing and retaining your personal information in line with our Privacy Policy which is available on: www.clientele.co.za.

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Add Additional Members
Insurance
* Mandatory Fields
Yes
Please complete your spouse’s personal details

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Yes
Please complete personal details for your child
Child 1



Children over 18 to 21 must be full-time students.


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Yes
Premium Pay Back Benefit – all the premiums of the insured deceased will be paid back.

Please note that Premium Pay Back benefit will be added to all or none of the covered extended members.


Please complete personal details for your extended member
Member 1



Cover Amount (Extended member’s cover amount may not exceed Main Member cover amount)

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Beneficiary Details

* Mandatory Fields
NOTE: Beneficiary allocation percentage must total 100% to continue.
ALLOCATED PERCENTAGE
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By submitting your details you consent to Clientèle processing and retaining your personal information in line with our Privacy Policy which is available on: www.clientele.co.za.
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Payer Details
Your Total Monthly Deduction:
Is  going to be paying the monthly premiums?
Yes
Please fill in your details below.

Bank Details


DebiCheck

Instant DebiCheck

Please note that you will receive a DEBICHECK message on your phone shortly, requesting you to confirm your debit order information with your bank. Please wait for the bank message to be pushed to your phone which might take a few seconds to come through. Once this happens, you should follow the instructions and respond accordingly.

If you do not receive this message now, your bank will be sending you a DEBICHECK SMS within the next day requesting you to confirm, electronically your debit order information. The SMS will contain instructions on where to confirm the information. You should respond to the DEBICHECK request immediately via your preferred banking channel like an ATM, Banking App, Cell phone Banking or at a branch.

Please note your valuable Ultimate H.E.L.P Plan will be on hold until you've successfully DebiChecked (authenticate) your debit order.

Delayed DebiCheck

Please note, you will receive a DEBICHECK SMS from your bank within the next day requesting you to confirm, electronically your debit order information with your bank. The SMS will contain instructions on where to confirm the information. The process is quick and easy and you should respond to the DEBICHECK request immediately via your preferred banking channel like an ATM, Banking App, Cell phone Banking or at a branch.

Please note your valuable Ultimate H.E.L.P Plan will be on hold until you've successfully DebiChecked (authenticate) your debit order.



Authorise
I hereby authorise Clientèle to draw against my bank account the premiums payable monthly, and I request my bank to debit my account in terms of this instruction using reasonable collection methods and tracking for however many days. Should Clientèle not be successful in obtaining the premium, I authorise them to resubmit their request to my bank at any time. I authorise Clientèle to debit my account up to 10 working days before my salary day except for December when the debit could be processed up to 15 working days before my salary day. This instruction will remain in force until cancelled by me. Should the relevant total premium be adjusted by Clientèle as a general increase/decrease in premium, or should I request Clientèle to increase/decrease the premium for certain reasons, I confirm that the adjusted premium may be deducted from my bank account until such time as I cancel this authorisation. Furthermore, I hereby authorise Clientèle to perform the necessary verification, validation and correction of the debit order details, supplied by me, with my bank or other third parties to ensure that this application form can be processed. Resubmission will be applied as aforementioned. The aforementioned debit order transactions will reflect as "CLIENTÈLE" (together with your policy number) on your bank statement.
I hereby authorise Clientèle to debit my bank account.
By submitting your details you consent to Clientèle processing and retaining your personal information in line with our Privacy Policy which is available on: www.clientele.co.za.
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Confirmation

Insurance
Your Premium
Your Email Address
This e-mail address will be used for all future communications.
Who is covered
edit
Benefits
Annual increases The premium will increase annually by 10% and the Cover Amount by 6%. Annual increases occur every 12 months from the start date of your policy.
Disclosure, disclaimer, authorisation and declaration


Download Disclaimer
I have read and agree with the terms and conditions.
By submitting your details you consent to Clientèle processing and retaining your personal information in line with our Privacy Policy which is available on: www.clientele.co.za.
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Thank you

Dear Valued Client,

Thank you for completing the application for . Please note your valuable Ultimate H.E.L.P Plan will be on hold until you've successfully DebiChecked (authenticate) your debit order.

Your monthly premium will be:

Your policy number is : .


Your documents will be emailed to you shortly. If you have any queries please contact our national call centre on 011 320 3000 or Email: services@clientele.co.za.
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