STRYDOM ONLINE APPLICATION

Policy Number: LA1002107
Pay@ Number: 11602990001002107
Submitted: 2026-06-25 08:50:44

EXISTING POLICY NUMBER: 
UPDATE EXISTING: 0
SERVICE PLAN: Single
PRODUCT PLAN: Standard
FIRST NAMES: Fiela
SURNAME: Delport
ID NUMBER: 5507120064083
DATE OF BIRTH: 12/07/1955
OLDEST MEMBER AGE: 70
AGE BAND USED: 65-74
INCEPTION DATE: 01/07/2026
MONTHLY PREMIUM: R146
REPRESENTATIVE NAME: Emmerentia Blaauw
REPRESENTATIVE CODE: 
REPRESENTATIVE BRANCH: Uniondale
REPRESENTATIVE CONTACT: 0603682095
EXISTING FUNERAL POLICY NUMBER: 
CASH COVER AMOUNT: 
ADDRESS: Hoenderverdors avontuur
POSTAL CODE: 6490
EMAIL: 
TELEPHONE: 
WORK NUMBER: 
CELLPHONE: 0716313159
WHATSAPP NUMBER: 0728497837
DEPENDENT 1 NAME: 
DEPENDENT 1 SURNAME: 
DEPENDENT 1 ID: 
DEPENDENT 1 RELATIONSHIP: 
DEPENDENT 1 PREMIUM: 
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: Erica
BENEFICIARY SURNAME: Delport
BENEFICIARY ID: 8804130138081
BENEFICIARY RELATIONSHIP: Daughter
PAYMENT METHOD: Cash
SOURCE OF FUNDS: Grant
TRANSFER REPLACEMENT: No
PREVIOUS INSURER: Mic fin
PREVIOUS POLICY NUMBER: Aa22693
PREVIOUS COVER START DATE: 18/04/2020
PREVIOUS CANCEL DATE: 
PROOF PREVIOUS COVER: Yes
SAME LIVES PREVIOUS POLICY: Yes
WAIVER REQUESTED: No
TRANSFER 1 NAME: Fiela
TRANSFER 1 SURNAME: Delport
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: Fiela
SIGNATURE DATE: 25/06/2026
TYPED SIGNATURE: F.delport

Signature: uploads/LA1002107_signature_20260625_085044.png

Uploads:
- uploads/LA1002107_id_copy_20260625_085044_17823771862306675056434660613404.jpg
- uploads/LA1002107_transfer_documents_0_20260625_085044_17823773487997763744483970783875.jpg
