Peaceguard
Client Registration Form
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1. Personal Information
Title:
Select
Mr
Mrs
Miss
Dr
Prof
Hon
Rev
Other
Ms
Full Names:
Surname:
ID Number / Passport Number:
Date of Birth:
Gender:
Select
Male
Female
Other
Race:
Select
Black
White
Indian
Coloured
Other
Primary Contact Number:
Alternative Contact Number:
Email Address:
Primary Residential Address:
Alternative Residential Address:
2. Next of Kin & Emergency Contacts
First Next of Kin
Full Names:
Surname:
Relationship to Next of Kin:
Primary Contact Number:
Alternative Contact Number:
Email Address:
Primary Residential Address:
Alternative Residential Address:
Second Next of Kin
Full Names:
Surname:
Relationship to Next of Kin:
Primary Contact Number:
Alternative Contact Number:
Email Address:
Primary Residential Address:
Alternative Residential Address:
3. Policy / Benefits / Financial Details
Category:
-- Select Category --
Life Cover
Funeral Cover
Retirement and Pension
Investment / Savings
Work Related
Bank Account
Current Employer
Education and Child Policies
Disability and Income Protection
Will
Stokvel
Other
Description:
Name of Institution/Organisation/Administrator:
Address/Location:
Start Date:
Still Active:
Select
Yes
No
Comments:
Add Another Policy
4. Payment Option
Select your preferred payment plan:
R100 every two months(i.e R50 per month)
R100
R150 every three months
R150
R300 every six months
R300
R500 annually
Includes a R100 discount
R500
Preferred Debit Order Day:
-- Select preferred day --
7th of the month
15th of the month
20th of the month
22nd of the month
25th of the month
27th of the month
Last day of the month
5. How did you hear about us? (Optional)
Name:
-- Please select --
Advertisement
Agent
Event or Expo
Friend or Family
Online Search
Radio
Social Media
Sports
Other
Please Specify:
Submit Information
Your information is securely encrypted and protected
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Employer Information
Employer Name:
1. Personal Information
Title:
Select
Mr
Mrs
Miss
Dr
Prof
Hon
Rev
Other
Ms
Full Names:
Surname:
ID Number / Passport Number:
Date of Birth:
Gender:
Select
Male
Female
Other
Race:
Select
Black
White
Indian
Coloured
Other
Primary Contact Number:
Alternative Contact Number:
Email Address:
Primary Residential Address:
Alternative Residential Address:
2. Next of Kin & Emergency Contacts
First Next of Kin
Full Names:
Surname:
Relationship to Next of Kin:
Primary Contact Number:
Alternative Contact Number:
Email Address:
Primary Residential Address:
Alternative Residential Address:
Second Next of Kin
Full Names:
Surname:
Relationship to Next of Kin:
Primary Contact Number:
Alternative Contact Number:
Email Address:
Primary Residential Address:
Alternative Residential Address:
3. Policy / Benefits / Financial Details
Category:
-- Select Category --
Life Cover
Funeral Cover
Retirement and Pension
Investment / Savings
Work Related
Bank Account
Current Employer
Education and Child Policies
Disability and Income Protection
Will
Stokvel
Other
Description:
Name of Institution/Organisation/Administrator:
Address/Location:
Start Date:
Still Active:
Select
Yes
No
Comments:
Add Another Policy
4. How did you hear about us? (Optional)
Name:
-- Please select --
Advertisement
Agent
Event or Expo
Friend or Family
Online Search
Radio
Social Media
Sports
Other
Please Specify:
Submit Information
Your information is securely encrypted and protected
Thank you! Your details are securely recorded. We'll follow up soon. Your reference number is [REFERENCE_NUMBER].
