Provident Funeral Plan Application Form

Use this form to apply for a Provident Funeral Plan.

1
Primary Credit Union Member:
  • This is the account your Credit Union will use to debit your monthly premium payments
2
Details of person to be insured:
  • Premium Rates table
    Premium Rates
3
Full name of beneficiary:
  • View terms and conditions
    • I understand and agree that the date signed below is the date that this insurance starts.
    • I understand and agree that this insurance policy has no investment or surrender value.
    • I understand and agree that I can cancel this insurance at any time by contacting my credit union.
    • I understand and agree that I can have a full copy of the group Insurance Policy by requesting it from my credit union.
    • I understand and agree that I am only covered for death by accidental causes for the first 24 months and that death by natural causes or suicide is not covered during the first 24 months.
    • I understand and agree that the premiums for this insurance will increase when higher age bands are reached, or the sum insured changes, or number of people insured changes or if I take up smoking or Pinnacle Life may increase premiums (for any reason) by giving 3 months prior notice.
    • I understand and agree that my credit union may be earning a fee from the sale of this insurance to me.
    • I understand and agree that my estate or surviving beneficiary must provide documentation to my credit union to support any claim on this insurance.
    • I understand and agree that I can only be insured once under the Policy even if I have accounts with more than one credit union.
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