SAMC Takaful Sign Up

Agent Details:

Agent Name & Surname:

Agent Code:

1. Personal Details:

Title:

Full Name:

Surname:

ID No.

Date of Birth:

Country of Birth:

Country of Residence:

Cell No.

Email Address:

Tel No (Home):

Tel No (Work):

2. Address:

Residential Address:

Postal Code:

Province:

Postal Address:

Postal Code:

3. Spouse & Dependent Children

Spouse Name:

Spouse Surname:

Spouse ID No.

Gender:

Child 1 Name:

Child 1 Surname:

Child 1 ID No or Date of Birth:

Gender:

Child 2 Name:

Child 2 Surname:

Child 2 ID No or Date of Birth:

Gender:

Child 3 Name:

Child 3 Surname:

Child 3 ID No or Date of Birth:

Gender:

Child 4 Name:

Child 4 Surname:

Child 4 ID No or Date of Birth:

Gender:

Child 5 Name:

Child 5 Surname:

Child 5 ID No or Date of Birth:

Gender:

4. Payment Options:

Payment Options

Total Monthly Collection

5. Debit Order Authorisation (if selected)

Please note: The South African Muslim Council has authorised Mahala Admin to facilitate all debits for the SAMC Takaful Membership.

I authorise Mahala Admin or its assignee to debit my bank account at below mentioned bank (or any other bank / branch to which I may transfer my account) with the Total Monthly Fees indicated above. Arrears will be collected by double debit. Should that double debit collection fail, ALL benefits will automatically lapse and be forfeited.

I confirm the above debit authorisation.

Account Type

Day of Debit

Bank:

Account Holder:

Account No.

Signature of Account Holder:

6. Nominated Beneficiary:

You may either appoint the SAMC as your beneficiary or you may nominate your own beneficiary. Please select your preferred option below:

Select Beneficiary

Full Name:

Surname:

ID No.

Date of Birth:

Relationship:

7. Declaration & Signature

I hereby apply for the benefits contained in this document. I declare that I have not withheld any material information. I am aware and have been explained of the waiting periods applicable to this policy.

By checking this box, you agree to receive promotional emails and other materials from Mahala Admin and its affiliates. Information requested is for Mahala Admin marketing purposes only and will not be sold or shared with a third party. Marketing emails provide a one-click method to unsubscribe from the distribution list.

The Mahala Admin protection of personal information policy is available for review at www.mahalaadmin.co.za. By taking out this product.

Mahala Admin confirms it will need to share certain relevant information with the insurer and/or other related parties.

I hereby consent to Mahala Admin performing these functions and sharing the information that is relevant. I realise if I do not provide this consent I will not be able to conclude this policy.

Participant / Principal Member Signature

Date: