Crystal Cover Membership Application

Please ensure all sections are completed accurately

Crystal Cover is a Jurisitic Representative of Kula Partners Advice, an authorised FSP (46670).

The funeral product is underwritten by RMA Life Assurance Company LTD, a licensed long-term insurer with PA registration number 10/10/1/116 and company registration number 1990/006308/06.

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1. Personal Information

Full Name

ID/Passport Number

Date of Birth

Gender

Male Female

Address

Postal Code

Phone

Nationality

2. Product Selection and Monthly Premium

Main Member (Entry Age 18-65)

Main Member & Family (Entry Age 18-65)

Main Member (Senior) (Entry Age 66-85)

Main Member (Senior) & Spouse (Entry Age 66-85)

Selected Plan

No plan selected

Monthly Premium

3. Extended Family Members

Add up to 10 extended family members (max age 84).

Surname	Name	ID/Passport Number	Date of Birth	Cover (R)	Premium (R)	Action

Premium Summary

Main Plan Premium

Extended Family Premium

Total Monthly Premium

4. Beneficiary Nomination

Beneficiary Name

Relationship to Member

Contact Number

Percentage of Benefit

5. Debit Order Authorization

I, [Your Name] , authorize Kula Partners to deduct the monthly membership fee from my bank account as per the details provided below.

Bank Name

Branch Code

Account Number

Account Type

Cheque Savings Other

Debit Order Date

Select the preferred day of the month for your debit order.

Waiting periods: A 3-month waiting period applies to natural death, 12 months for suicide, and none for accidental death.

6. Declaration and Consent

I declare that the information provided in this form is true and correct. I understand that any false or misleading information may result in my membership being voided. I consent to my personal information being used for the purpose of administering my membership and policy.

By signing this application form, the policyholder expressly consents to the potential transfer of the policy to an alternative registered underwriter at any time during the policy term. Such transfer may be effected without the need for further consent from the policyholder, provided that the intermediary undertakes to ensure continuity of cover. All material rights and obligations under the policy will remain unchanged unless otherwise communicated in writing.

Signature (sign inside the box)

Date

I agree to the terms and conditions

Select Agent:

Agent Name:

Agent Code:

7. Supporting Documents (Upload or Scan)

Upload Files

Drag & drop files here, or click to select.

Accepted: PDF, JPG, PNG, HEIC, WEBP, TIFF. Max 10MB per file.

Scan with Camera

Use your device camera to capture documents.