STRYDOM ONLINE APPLICATION

Policy Number: LA1002111
Pay@ Number: 11602990001002111
Submitted: 2026-06-26 09:43:44

EXISTING POLICY NUMBER: 
UPDATE EXISTING: 0
SERVICE PLAN: 1+9
PRODUCT PLAN: Standard
FIRST NAMES: Bentley
SURNAME: Branders
ID NUMBER: 6108085178080
DATE OF BIRTH: 08/08/1961
OLDEST MEMBER AGE: 64
AGE BAND USED: 18-64
INCEPTION DATE: 01/07/2026
MONTHLY PREMIUM: R280
REPRESENTATIVE NAME: Luceul mentoor
REPRESENTATIVE CODE: 
REPRESENTATIVE BRANCH: Conville
REPRESENTATIVE CONTACT: 0782678140
EXISTING FUNERAL POLICY NUMBER: 
CASH COVER AMOUNT: 
ADDRESS: 75 swamstraat
Parkdene
POSTAL CODE: 6529
EMAIL: 
TELEPHONE: 0634306050
WORK NUMBER: 
CELLPHONE: 0634306050
WHATSAPP NUMBER: 0634306050
DEPENDENT 1 NAME: Lizelle
DEPENDENT 1 SURNAME: Tarentaal
DEPENDENT 1 ID: 9503031475084
DEPENDENT 1 RELATIONSHIP: 
DEPENDENT 1 PREMIUM: 
DEPENDENT 2 NAME: Leroy
DEPENDENT 2 SURNAME: Tarentaal
DEPENDENT 2 ID: 0510245104086
DEPENDENT 2 RELATIONSHIP: 
DEPENDENT 2 PREMIUM: 
DEPENDENT 3 NAME: Leane
DEPENDENT 3 SURNAME: Tarentaal
DEPENDENT 3 ID: 1905160246087
DEPENDENT 3 RELATIONSHIP: 
DEPENDENT 3 PREMIUM: 
DEPENDENT 4 NAME: Brendan-lee
DEPENDENT 4 SURNAME: Tarentaal
DEPENDENT 4 ID: 9907265509080
DEPENDENT 4 RELATIONSHIP: 
DEPENDENT 4 PREMIUM: 
DEPENDENT 5 NAME: Raylene
DEPENDENT 5 SURNAME: Tarentaal
DEPENDENT 5 ID: 0805080738083
DEPENDENT 5 RELATIONSHIP: 
DEPENDENT 5 PREMIUM: 
EXTENDED 1 NAME: Marelize
EXTENDED 1 SURNAME: Tarentaal
EXTENDED 1 ID: 9009091615080
EXTENDED 1 RELATIONSHIP: 
EXTENDED 1 PREMIUM: 
EXTENDED 2 NAME: Gersma
EXTENDED 2 SURNAME: Bruintjies
EXTENDED 2 ID: 1708130379081
EXTENDED 2 RELATIONSHIP: 
EXTENDED 2 PREMIUM: 
EXTENDED 3 NAME: Micayla
EXTENDED 3 SURNAME: Bruintjies
EXTENDED 3 ID: 1512090423081
EXTENDED 3 RELATIONSHIP: 
EXTENDED 3 PREMIUM: 
EXTENDED 4 NAME: Glentino
EXTENDED 4 SURNAME: Bruintjies
EXTENDED 4 ID: 1907125582085
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: Lizelle
BENEFICIARY SURNAME: Tarentaal
BENEFICIARY ID: 9503031475084
BENEFICIARY RELATIONSHIP: Daughter
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: Bentley
SIGNATURE DATE: 26/06/2026
TYPED SIGNATURE: Bentley branders

Signature: uploads/LA1002111_signature_20260626_094344.png
