Doves Group Input Form

Details of Contact Person

Title

Surname

Name

Please note: at least one contact number is required!
Use this number in all three fields if no other contact numbers

Mobile number

Telephone No: Home
(include area code)

Telephone No: Work
(include area code)

Email Address

Province

The following information is needed for a Group funeral scheme quotation:

Do you have a current scheme or not:
Yes
No

Are the members geographically spread, or are all members in the one province:

Yes
No

Age Category	Amount of members in this age group
20-30	(enter 0 if zero)
30-40	(enter 0 if zero)
40-50	(enter 0 if zero)
50-60	(enter 0 if zero)
60-70	(enter 0 if zero)
70 and older	(enter 0 if zero)

Indicate % of male employees:
(enter 0 if zero)

Indicate % of female employees:
(enter 0 if zero)

Cover Amount:
R5 000
R10 000

Children included:
Yes
No

Extented Family (patents/in-laws/brothers etc.):
Yes
No

Comments

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