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

When selecting EFT as your payment option, please deposit your monthly contribution into the following account:

Bank: alBaraka Bank
Account Holder: South African Muslim Council
Account Type: Current
Account Number: 7860 0394 221
Branch Code: 800 000

Important! Please use your ID number as your Reference number to ensure your contribution is allocated correctly.

5. 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:

6. 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

Agent Name & Surname:

Date: