STRYDOM ONLINE APPLICATION

Policy Number: LA1002009
Pay@ Number: 11602990001002009
Submitted: 2026-06-10 13:47:05

EXISTING POLICY NUMBER: 
UPDATE EXISTING: 0
SERVICE PLAN: 1+5
PRODUCT PLAN: Standard
FIRST NAMES: Lidiia
SURNAME: Arries
ID NUMBER: 5410080622083
DATE OF BIRTH: 08/10/1954
OLDEST MEMBER AGE: 71
AGE BAND USED: 65-74
INCEPTION DATE: 01/07/2026
MONTHLY PREMIUM: R285
REPRESENTATIVE NAME: Simon Manuel
REPRESENTATIVE CODE: 
REPRESENTATIVE BRANCH: Willowmore
REPRESENTATIVE CONTACT: 0720693732
EXISTING FUNERAL POLICY NUMBER: 
CASH COVER AMOUNT: 
ADDRESS: 5de Laan 284
POSTAL CODE: 6445
EMAIL: 
TELEPHONE: 
WORK NUMBER: 
CELLPHONE: 0639276239
WHATSAPP NUMBER: 0639276239
DEPENDENT 1 NAME: Venus
DEPENDENT 1 SURNAME: Arries
DEPENDENT 1 ID: 8210040067081
DEPENDENT 1 RELATIONSHIP: Mother in law
DEPENDENT 1 PREMIUM: 
DEPENDENT 2 NAME: Kobus
DEPENDENT 2 SURNAME: Arries
DEPENDENT 2 ID: 8403145236087
DEPENDENT 2 RELATIONSHIP: Son
DEPENDENT 2 PREMIUM: 
DEPENDENT 3 NAME: Nellie
DEPENDENT 3 SURNAME: Arries
DEPENDENT 3 ID: 7809300209084
DEPENDENT 3 RELATIONSHIP: Daughter
DEPENDENT 3 PREMIUM: 
DEPENDENT 4 NAME: Eveliena
DEPENDENT 4 SURNAME: Ariies
DEPENDENT 4 ID: 1509220639081
DEPENDENT 4 RELATIONSHIP: Grand child
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: Venus
BENEFICIARY SURNAME: Arries
BENEFICIARY ID: 8210040067081
BENEFICIARY RELATIONSHIP: Mother in law
PAYMENT METHOD: Cash
SOURCE OF FUNDS: Grant
TRANSFER REPLACEMENT: No
PREVIOUS INSURER: 
PREVIOUS POLICY NUMBER: 
PREVIOUS COVER START DATE: 
PREVIOUS CANCEL DATE: 
PROOF PREVIOUS COVER: No
SAME LIVES PREVIOUS POLICY: No
WAIVER REQUESTED: No
TRANSFER 1 NAME: 
TRANSFER 1 SURNAME: 
TRANSFER 1 ID: 
TRANSFER 1 COVER AMOUNT: 
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: Lidia Arries
SIGNATURE DATE: 10/06/2026
TYPED SIGNATURE: Venus Arries

Signature: uploads/LA1002009_signature_20260610_134705.png
