Online Application Form

Section 1: Personal Information

Full Name (as per ID) *

ID Number *

Date of Birth *

Gender *

Male

Female

Other

Marital Status

Nationality

Home Address

Postal Address (if different)

Province

City/Town

Contact Number (Cell) *

Alternative Contact Number

Email Address *

Section 2: Employment & Income Details

Occupation

Employer Name

Employer Contact Number

Monthly Income Range

Under R2,000

R2,000–R5,000

R5,001–R10,000

Above R10,000

Preferred Payment Method

Cash

Debit Order

Stop Order

EFT

Section 3: Plan Selection

Funeral Cover Packages (1 main member + 9 dependants)
Joining Fee: R250 (once-off) — 6-month waiting period applies. Policy lapses after 3 months of non-payment. We only provide burials; no cash payouts. Each plan covers 1 main member + 9 dependants.

PLAN A — Flat-Lid Burial Package R250/month

Services include: Flat-Lid Coffin for all dependants; 1 Hearse; 1 Family Car; 1 Grave Marker; 1 Toilet; 122-Seater Tent; 40 Chairs; 2 Tables.

PLAN B — 3-Tier Burial Package R350/month

Services include: 3-Tier Coffin for Main Member & Beneficiary; Flat-Lid Coffin for dependants; 1 Hearse; 1 Family Car; 1 Grave Marker; 1 Toilet; 122-Seater Tent; 40 Chairs; 2 Tables.

PLAN C — Prestige Burial Package R450/month

Services include: Open-Face Budget Casket for Main Member & Beneficiary; Flat-Lid Coffin for dependants; 1 Hearse; 2 Family Cars; 1 Bus; 1 Big Tent; 60 Chairs; 4 Tables; 100 Glasses & 150 Plates; 1 Grave Marker; 1 Toilet.

Plan Option (select variant)

Selected Cover Amount

Premium Amount per Month

Preferred Payment Date

I acknowledge the R250 joining fee, the 6-month waiting period, the 3-month lapse for non-payment, and that Vusana Funeral Service provides burial services only (no cash payouts).

Section 4: Beneficiary Details

Beneficiary Full Name

Relationship

ID Number

Contact Number

Address

Section 5: Dependants (for Family Plans)

Full Name	Relationship	ID Number	Date of Birth	Gender	Remove

Section 6: Next of Kin / Emergency Contact

Full Name

Relationship to Applicant

Contact Number

Address

Section 7: Documents Upload

Applicant’s ID (jpg, png, pdf)

Beneficiaries’ IDs / Birth Certificates (you may choose multiple)

Proof of Residence

Payslip / Proof of Income (if required)

Section 8: Terms and Declaration

Do you confirm that all the information provided is true and correct? *

Yes

Do you authorise Vusana Funeral Service to debit your account monthly for premium payments?

Yes

Do you agree to the company’s Terms & Conditions and Privacy Policy? *

Yes

I confirm the information provided is true and I consent to Vusana Funeral Service using my information to process this application in line with POPIA.

Signature (Type full name) *

Date of Application *

Section 9 (Optional): Marketing & Communication

How did you hear about Vusana Funeral Service?

Would you like to receive updates or promotions?

Yes