Application Form

Income Sure

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    Personal Details

  • Policy Holder Protection Data (Compulsory)
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    Telephone details

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    Weekly Cashflow Protector (Weekly Benefit)

  • Weekly Cashflow Protector (Weekly Benefit) 30 day waiting period (excess) (14 days Virgin Active Instructors) for sickness 7 day for accident. Up to maximum 104 weeks excluding waiting period
  • Weekly Cashflow Protector (Weekly Benefit) 30 day waiting period (excess) (14 days Virgin Active Instructors) for sickness 7 day for accident. Up to maximum 104 weeks excluding waiting period
  • 30 day waiting period (excess) (14 days Virgin Active Instructors) 7 day waiting period for accident (excess) Up to maximum 24 months excluding waiting period
  • 30 day waiting period (excess) (14 days Virgin Active Instructors) 7 day waiting period for accident (excess) Up to maximum 24 months excluding waiting period
  • 30 day waiting period (excess) (14 days Virgin Active Instructors) 7 day waiting period for accident (excess) Up to maximum 24 months excluding waiting period This is for self-employed persons to cover business overheads and excluding the Insured Person's earnings which must be insured under the Weekly Cashflow Protector benefit
  • (All Cancers except skin cancer) Fixed benefit on diagnosis
  • Fixed benefit on birth of a child after 12 consecutive months on the policy
  • This is the total of the benefits chosen above as well as the Compulsory benefit of R50.00 and the Policy fee of R15.00
    R0.00
  • I hereby authorise LSG Insurance Services (Pty) Ltd or its authorised administrator to debit my account with the agreed monthly premium payment at:
  • NOTE: Debits cannot be raised through FNB Savings, Master Card Holders, or account numbers exceeding 13 digits
  • R0.00
      • I/we declare that after proper enquiry the statements and particulars given above are true and that I/we have not miss-stated or suppressed any material fact.
      • I/we agree that this Proposal Form, together with any other material information supplied by me/us shall form the basis of any contract of insurance affected thereon.
      • I/we undertake to inform underwriters of any material alteration to these facts occurring before the completion of the contract.
      • I/We understand that submitting this electronic declaration form will from the basis of this contract.
      • I/We understand that the premium includes regulated commission, charged at 20% of the gross premium, payable to the broker for services provided. I/we consent to a R80.00 broker fee* and either a R11.40 debit order charge or R15.00 cash deposit charge (whichever is applicable).*Explained in LSG Financial Services Guide.
      • Insurance is not bound until accepted by insurers
      • Insurers share information with each other regarding policies and claims with a view to prevent fraudulent claims and obtain material information regarding the assessment of risks proposed for insurance. By reducing the incidents of fraud and assessing risks fairly, future premium increases may be limited.  This is done in the public interest and in the interest of all current and potential policyholders. The sharing of information includes, but is not limited to information sharing via the Information Data Sharing System operated by TransUnion ITC on behalf of the South African Insurance Association. By the insurer accepting this insurance, you or any other person that is represented herein, gives consent to the said information being disclosed to any other insurance company or its agent. You also similarly give consent to the sharing of information in regards to past insurance policies and claims that you have made. You also acknowledge that information provided by yourself or your representative may be verified against any legally recognised sources or databases. By insuring you hereby not only consent to such information sharing, but also waive any rights of confidentiality with regards to underwriting or claims information that you have provided or that has been provided by another person on your behalf. In the event of a claim, the information you have supplied with your application together with the information you supply in relation to the claim, will be included on the system and made available to other insurers participating in the Information Data Sharing System.
      • When you enter into this policy you will be giving us your personal information that may be protected by data protections legislation, including but not only, the Protection of Personal Information Act, 2013 (“POPI”). We will take all reasonable steps to protect your personal information. You authorise us to:
        1. Process your personal information to
          1. Communicate information to you that you ask us for.
          2. Provide you with insurance services.
          3. Verify the information you have given us against any source or database.
          4. Compile non-personal statistical information about you.
        2. Transmit your personal information to any affiliate, subsidiary or re-insurer so that we can provide insurance services to you and to enable us to further our legitimate interests including statistical analysis, re-insurance and credit control.
        3. Transmit your personal information to any third party service provider that we may appoint to perform functions relating to your policy on our behalf.
      • You acknowledge that this consent clause will remain in force even if your policy is cancelled or lapsed.
      Copy of policy wording available on request.