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BCCCI Nomination Forms 2022 v1

This document is a nomination form for beneficiaries under a family crisis plan insured by Constantia Life & Health Assurance Company. It requests key details about the main member, their spouse/partner, any dependent children under age 21 (or 25 if a student), and the nominated beneficiary. The completed form should be mailed or emailed to Ambledown Financial Services along with relevant documentation to ensure the member's dependents are covered. Assistance is available by calling the provided numbers.

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37 views1 page

BCCCI Nomination Forms 2022 v1

This document is a nomination form for beneficiaries under a family crisis plan insured by Constantia Life & Health Assurance Company. It requests key details about the main member, their spouse/partner, any dependent children under age 21 (or 25 if a student), and the nominated beneficiary. The completed form should be mailed or emailed to Ambledown Financial Services along with relevant documentation to ensure the member's dependents are covered. Assistance is available by calling the provided numbers.

Uploaded by

nonkolisekonkwanyana14
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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2019 [v1]

BCCCI FAMILY CRISIS PLAN NOMINATION FORM


Underwritten by Constantia Life & Health Assurance Company Limited, Registration Number 1952/001635/06, (The Insurer)

This form MUST be completed and returned to Ambledown Financial Services to ensure your dependants are covered.
Leli fomu KUFANELWE ligcwaliswe bese libuyiselwa kwa Ambledown Financial Services ukuqinisekisa ukuthi abondliwa bakho bakhavekile.
Please post this completed form with all relevant documentation to: Ambledown Financial Services (Pty) Ltd, PO Box 1862, Cramerview, 2060,
or fax to: 011 463 1665 or email to [email protected] and cc [email protected]
For assistance please call Ambledown on 0800 800 030 or Healthcor Projects (Pty) Ltd on 064 922 8489 or 083 278 4680

MAIN MEMBER DETAILS / IMINININGWANE YOMNINI PHOLISI UNION DETAILS


MEMBER NAME SATAWU
IGAMA LELUNGA NAGEWU
MEMBER SURNAME THOR
ISIBONGO SELUNGA OTHER
EMPLOYEE NUMBER NONE
ID/PASSPORT NUMBER COUNTRY OF RESIDENCE
DATE OF BIRTH D D M M Y Y Y Y COUNTRY OF NATIONALITY
CELL NUMBER CODE FACE TO FACE YES NO
COMPANY NAME EMAIL
OCCUPATION INDUSTRY
BCCCI BRANCH BCCCI SITE
POSTAL ADDRESS PHYSICAL ADDRESS

POSTAL CODE POSTAL CODE

SPOUSE OR PARTNER DETAILS / IMINININGWANE YOMUNTU OSHADE NAYE OKANYE UMAQONDANA WAKHO
SPOUSE / PARTNER NAME
IGAMA LIKAMAQONDANA
SPOUSE / PARTNER SURNAME
ISIBONGO SIKAMAQONDANA
ID OR PASSPORT NUMBER
DATE OF BIRTH D D M M Y Y Y Y
CELL NUMBER CODE

NAMES OF CHILDREN UP TO 21 YEARS OF AGE (25 YEARS IF FULL TIME STUDENT)


AMAGAMA EZINGANE KUGCINA EMINYAKENI ENGU 21 (25 UMA ENGUMFUNDI)
SA I.D. NUMBER / RELATIONSHIP TO PRINCIPAL
FIRST NAME / IGAMA SURNAME / ISIBONGO
IF NO SA I.D. NUMBER ENTER DATE OF BIRTH MEMBER

BENEFICIARY DETAILS / IMININGWANE KANDLALIFA (If the nomimated beneficiary is a minor, the claimant will need to provide guardianship at claim stage.)
BENEFICIARY NAME
IGAMA LIKANDLALIFA
BENEFICIARY SURNAME
ISIBONGO SIKANDLALIFA
BENEFICIARY RELATIONSHIP:
UBUDLELWANO NONDLALIFA:
ID OR PASSPORT NUMBER
DATE OF BIRTH D D M M Y Y Y Y
CELL NUMBER CODE TELEPHONE NUMBER CODE

SIGNATURE OF MEMBER DATE D D M M Y Y Y Y

Broker Details: Healthcor Projects (Pty) Ltd. FSP Number: 17862


Ambledown is an Authorised Financial Services Provider, No. 10287 Tel: 064 922 8489/ 083 278 4680 PO B ox 1735, Umhlanga Rocks, 4320 Underwritten by Constantia Life & Health Assurance Company
Limited, Registration Number 1952/001635/06

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