Quotation & Application Free Instant Quotation Complete the short form below for a free and instant no-obligations Legal4me Cover Plan quotation:First Name*Surname*Email*Cell Phone*Type of Plan*Individual PlanFamily Plan Free Instant Quotation Awesome! Below is your monthly premium which, I'm sure you'll agree, is not too shabby at all:Monthly Premium Price: R0.00 Legally Empower Yourself and Your Loved Ones Download an application form here, or conveniently apply online by clicking the "Apply Online" button below: Legal4me Cover Plan Application Complete the form below to apply conveniently online:Principal Insured's DetailsTitle*Mr.Ms.Gender*MaleFemaleInitials*Full Name(s)*Surname*Identification TypeRSA IDRSA/Foreign PassportRSA ID Number*RSA/Foreign Passport No.*Date of Birth* Date Format: DD slash MM slash YYYY Email Address* Physical Address* Street Address Address Line 2 City Province Postal Code Postal Address* Same as Physical Street Address Address Line 2 City Province Postal Code Work Phone*Cell Number*Home PhoneFax NumberFamily Members to be CoveredSpouse DetailsFull Name(s)SurnameID/Passport No.Children's DetailsFull Name(s)SurnameID/Passport No. Use the and icons to add or remove fields for childrenPlan Selection DetailsLegal4me Plan SelectionMonthly DeductionBank & Debit Order DetailsAccount Holder*Bank Name & Code*Select Your Bank...Absa Bank - 632005African Bank- 430000Capitec Bank - 470010First National Bank (SA) - 250655Investec Bank - 580105MTN Banking - 490991Meeg Bank - 71001Nedbank (SA) - 198765Postbank - 460005Standard Bank (SA) - 051001Albaraka Bank - 800000Bank Of Namibia - 980172Bidvest Bank - 462005Central Bank of Lesotho - 586611Citi Bank - 350005Finbond Mutual Bank - 589000First National Bank Lesotho - 280061First National Bank Namibia - 282672First National Bank Swaziland - 280164Grinrod Bank - 584000HSBC Bank - 587000JP Morgan Chase Bank - 432000Standard Bank of Namibia - 087373State Bank of India - 801000Ubank - 431010Unibank - 790005VBS Mutual Bank - 588000Account Number*When Sould Your Policy Start?*Please Select...This MonthNext MonthThe Month After NextInception Date: Inception DateInception DateInception DateDebit Order Date*Select the Day of the Month...1st of the Month7th of the Month15th of the Month27th of the MonthActivation Fee Price: R0.00 Total First Month DeductionMonthly premium plus activation fee (R50 if Individual Plan, R75 if Family Plan)Normal Monthly PremiumThe usual monthly premium from the 2nd. month onwardAgreement to Terms & ConditionsPlease note that the Terms and Conditions stipulated below must be read and accepted along with the stipulations of the Policy Document, which contains the Statutory Notices and other Legal Requirements. Please CLICK HERE to DOWNLOAD (opens a new page) the policy document, and familiarise yourself with the contents thereof.Terms and Conditions*I warrant that I have been provided with all the information, insurer and cover details, or any additional information as I may have requested. I warrant that all details and facts provided herein are accurate and properly disclosed, even if completed by a representative on my behalf. I warrant that the covers offered are risk covers only and that there are no surrender values. Failure to pay premiums will result in the policy lapsing. In the event of any query regarding this policy or any claim in terms of this policy, I consent to the disclosure of any relevant information to the Intermediary or any Official of the Administrator/Insurer for the purpose of resolving the query. In the event of no nominated beneficiary, I agree that any claim amount will be paid directly to the Insured's Estate or will be payable to the first claimant with reasonable title to claim. I hereby accept and understand that this is an Assistance Assurance Policy and the premium is payable in advance on a month to month basis and that the Insurer can increase the premiums with one month's notice as per policy document in the event that the claims ratio increases above 70% of the risk premium. I authorise that such increase may be added to the current stated premium to be deducted from my bank account or salary after I was given 1 Calendar Month's notice by post, email or SMS. I acknowledge that I have received a copy of the Statutory Notice and other Legal Requirements or have access to it. I understand and accept that this service is rendered without a full financial needs analysis and I took particular care in the product selection. I accept and understand that my documentation will only be posted to my requested address in the month after the first premium deduction was successfully done and cleared by the Administrator's bank only if I specifically request it. I understand and accept the waiting periods that apply on the policy options selected. I agree to the Terms and Conditions Affordability* I hereby declare that I can afford to pay the quoted monthly premium, and that I am not over-committing myself financially. Promotional Code (optional)If you have a promotional code, enter it hereIntermediary (optional)NameCodeIf you are a broker or agent, enter your code hereIntermediary EmailIntermediary Cellphone This iframe contains the logic required to handle Ajax powered Gravity Forms.