STRYDOM ONLINE APPLICATION

Policy Number: LA1002086
Pay@ Number: 11602990001002086
Submitted: 2026-06-24 08:41:54

EXISTING POLICY NUMBER: 
UPDATE EXISTING: 0
SERVICE PLAN: Single
PRODUCT PLAN: Standard
FIRST NAMES: Raymondo
SURNAME: Blaauw
ID NUMBER: 0704176286083
DATE OF BIRTH: 17/04/2007
OLDEST MEMBER AGE: 19
AGE BAND USED: 18-64
INCEPTION DATE: 01/07/2026
MONTHLY PREMIUM: R85
REPRESENTATIVE NAME: Emmerentia Blaauw
REPRESENTATIVE CODE: 
REPRESENTATIVE BRANCH: Uniondale
REPRESENTATIVE CONTACT: 0603682095
EXISTING FUNERAL POLICY NUMBER: 
CASH COVER AMOUNT: 
ADDRESS: Hoenderverdors avontuur
POSTAL CODE: 6499
EMAIL: 
TELEPHONE: 
WORK NUMBER: 
CELLPHONE: 0716313159
WHATSAPP NUMBER: 0728497837
DEPENDENT 1 NAME: Raymondo
DEPENDENT 1 SURNAME: Blaauw
DEPENDENT 1 ID: 
DEPENDENT 1 RELATIONSHIP: 
DEPENDENT 1 PREMIUM: R20000
DEPENDENT 2 NAME: 
DEPENDENT 2 SURNAME: 
DEPENDENT 2 ID: 
DEPENDENT 2 RELATIONSHIP: 
DEPENDENT 2 PREMIUM: 
DEPENDENT 3 NAME: 
DEPENDENT 3 SURNAME: 
DEPENDENT 3 ID: 
DEPENDENT 3 RELATIONSHIP: 
DEPENDENT 3 PREMIUM: 
DEPENDENT 4 NAME: 
DEPENDENT 4 SURNAME: 
DEPENDENT 4 ID: 
DEPENDENT 4 RELATIONSHIP: 
DEPENDENT 4 PREMIUM: 
DEPENDENT 5 NAME: 
DEPENDENT 5 SURNAME: 
DEPENDENT 5 ID: 
DEPENDENT 5 RELATIONSHIP: 
DEPENDENT 5 PREMIUM: 
EXTENDED 1 NAME: 
EXTENDED 1 SURNAME: 
EXTENDED 1 ID: 
EXTENDED 1 RELATIONSHIP: 
EXTENDED 1 PREMIUM: 
EXTENDED 2 NAME: 
EXTENDED 2 SURNAME: 
EXTENDED 2 ID: 
EXTENDED 2 RELATIONSHIP: 
EXTENDED 2 PREMIUM: 
EXTENDED 3 NAME: 
EXTENDED 3 SURNAME: 
EXTENDED 3 ID: 
EXTENDED 3 RELATIONSHIP: 
EXTENDED 3 PREMIUM: 
EXTENDED 4 NAME: 
EXTENDED 4 SURNAME: 
EXTENDED 4 ID: 
EXTENDED 4 RELATIONSHIP: 
EXTENDED 4 PREMIUM: 
EXTENDED 5 NAME: 
EXTENDED 5 SURNAME: 
EXTENDED 5 ID: 
EXTENDED 5 RELATIONSHIP: 
EXTENDED 5 PREMIUM: 
EXTENDED 6 NAME: 
EXTENDED 6 SURNAME: 
EXTENDED 6 ID: 
EXTENDED 6 RELATIONSHIP: 
EXTENDED 6 PREMIUM: 
EXTENDED 7 NAME: 
EXTENDED 7 SURNAME: 
EXTENDED 7 ID: 
EXTENDED 7 RELATIONSHIP: 
EXTENDED 7 PREMIUM: 
EXTENDED 8 NAME: 
EXTENDED 8 SURNAME: 
EXTENDED 8 ID: 
EXTENDED 8 RELATIONSHIP: 
EXTENDED 8 PREMIUM: 
EXTENDED 9 NAME: 
EXTENDED 9 SURNAME: 
EXTENDED 9 ID: 
EXTENDED 9 RELATIONSHIP: 
EXTENDED 9 PREMIUM: 
EXTENDED 10 NAME: 
EXTENDED 10 SURNAME: 
EXTENDED 10 ID: 
EXTENDED 10 RELATIONSHIP: 
EXTENDED 10 PREMIUM: 
BENEFICIARY NAME: Fiela
BENEFICIARY SURNAME: Delport
BENEFICIARY ID: 5507120064083
BENEFICIARY RELATIONSHIP: Kleinkind
PAYMENT METHOD: Cash
SOURCE OF FUNDS: Salary
TRANSFER REPLACEMENT: No
PREVIOUS INSURER: Mic fin
PREVIOUS POLICY NUMBER: Hm 22690
PREVIOUS COVER START DATE: 06/05/2020
PREVIOUS CANCEL DATE: 
PROOF PREVIOUS COVER: Yes
SAME LIVES PREVIOUS POLICY: Yes
WAIVER REQUESTED: No
TRANSFER 1 NAME: Raymondo
TRANSFER 1 SURNAME: Blaauw
TRANSFER 1 ID: 
TRANSFER 1 COVER AMOUNT: R20000
TRANSFER 2 NAME: 
TRANSFER 2 SURNAME: 
TRANSFER 2 ID: 
TRANSFER 2 COVER AMOUNT: 
TRANSFER 3 NAME: 
TRANSFER 3 SURNAME: 
TRANSFER 3 ID: 
TRANSFER 3 COVER AMOUNT: 
TRANSFER 4 NAME: 
TRANSFER 4 SURNAME: 
TRANSFER 4 ID: 
TRANSFER 4 COVER AMOUNT: 
TRANSFER 5 NAME: 
TRANSFER 5 SURNAME: 
TRANSFER 5 ID: 
TRANSFER 5 COVER AMOUNT: 
TRANSFER 6 NAME: 
TRANSFER 6 SURNAME: 
TRANSFER 6 ID: 
TRANSFER 6 COVER AMOUNT: 
TRANSFER 7 NAME: 
TRANSFER 7 SURNAME: 
TRANSFER 7 ID: 
TRANSFER 7 COVER AMOUNT: 
NATURAL MONTHS SERVED: 
NATURAL APPLICABLE WAITING: 6 Months
ACCIDENTAL MONTHS SERVED: 
ACCIDENTAL APPLICABLE WAITING: 0 Months
SUICIDE MONTHS SERVED: 
SUICIDE APPLICABLE WAITING: 12 Months
SIGNATURE NAME: Raymondo
SIGNATURE DATE: 24/06/2026
TYPED SIGNATURE: R.Blaauw

Signature: uploads/LA1002086_signature_20260624_084154.png

Uploads:
- uploads/LA1002086_id_copy_20260624_084154_17822902624232754515544657425425.jpg
- uploads/LA1002086_transfer_documents_0_20260624_084154_1782290390265925683372466637891.jpg
