Afterlife CCA – Funeral Homes & Policies

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Country *

Church of Fellowship *

Name of Church Leader *

Select Policy *

Payment Method of choice *

Main Member Title *

Mr / Mrs / Miss / Dr / Archbishop / Bishop / Pastor / Etc

Main Member Full Name & Surname *

First

Middle

Last

Main Member Gender *

Main Member ID Number / Passport Number *

Main Member Date Of Birth *

YYYY/MM/DD

Cellphone Number *

Cellphone Number Whatsapp *

Cellphone Number Alternative *

Email Address *

What is the best way to communicate with you? *

Would you like Marketing Information from CCA? *

Profession *

Physical Address *

Who will all be covered? *

Main Member (you)
Spouse (My Husband/Wife)
Child 1 (under age 21)
Child 2 (under age 21)
Child 3 (under age 21)
Child 4 (under age 21)
Child 5 (under age 21)

Spouses Full Name & Surname

First

Middle

Last

Gender

Spouse ID Number / Passport Number

Spouse Date Of Birth

YYYY/MM/DD

Spouse Cellphone Number

Spouse Email Address

Child 1 Full Name & Surname

First

Middle

Last

Child 1 Gender

Child 1 ID Number / Passport Number

Child 1 Date Of Birth

YYYY/MM/DD

Child 2 Full Name & Surname

First

Middle

Last

Child 2 Gender

Child 2 ID Number / Passport Number

Child 2 Date Of Birth

YYYY/MM/DD

Child 3 Full Name & Surname

First

Middle

Last

Child 3 Gender

Child 3 ID Number / Passport Number

Child 3 Date Of Birth

YYYY/MM/DD

Child 4 Full Name & Surname

First

Middle

Last

Child 4 Gender

Child 4 ID Number / Passport Number

Child 4 Date Of Birth

YYYY/MM/DD

Child 5 Full Name & Surname

First

Middle

Last

Child 5 Gender

Child 5 ID Number / Passport Number

Child 5 Date Of Birth

YYYY/MM/DD

Do you want to cover Extended Family? Eg Sister, Mom, Aunty, Grandmother Etc

If Yes, Please fill in the below information

Select Policy For Extended Family Member 1

Relationship of Extended Family Member 1

Aunty, Gogo, Brother, Etc

Extended Family Member 1 Full Name & Surname

First

Middle

Last

Extended Family Member 1 Gender

Extended Family Member 1 ID Number / Passport Number

Extended Family Member 1 Date of Birth

Select Policy For Extended Family Member 2

Relationship of Extended Family Member 2

Extended Family Member 2 Full Name & Surname

First

Middle

Last

Extended Family Member 2 Gender

Extended Family Member 2 ID Number / Passport Number

Extended Family Member 2 Date of Birth

Select Policy For Extended Family Member 3

Relationship of Extended Family Member 3

Extended Family Member 3 Full Name & Surname

First

Middle

Last

Extended Family Member 3 Gender

Extended Family Member 3 ID Number / Passport Number

Extended Family Member 3 Date of Birth

I have more Extended Members to add - Please call me on this cell number

I have read and understand the Terms and Conditions stated on https://afterlifecca.com/test

Yes
No

I have paid my first installment with the Representative

Yes
No

Accept this as my electronic signature as I agree that the above information is true and fave

Yes
No

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