Afterlife CCA – Funeral Homes & Policies

New Registration Form

This Is a New Registration Form

Please enable JavaScript in your browser to complete this form.Select Policy *Title *Mr / Mrs / Miss / Dr / Archbishop / Bishop / Pastor / Etc

Full Name & Surname *FirstMiddleLast

ID Number / Passport Number *Date Of Birth *YYYY/MM/DDCellphone Number *Cellphone Number 2Cellphone Number 3Email Address *Profession *Physical Address *Church of Fellowship *Name of Church Leader *

Select Beneficiaries of Policy *

Spouses Full Name & Surname *FirstMiddleLast

Spouse ID Number / Passport Number *Spouse Date Of Birth *YYYY/MM/DDSpouse Cellphone Number *Spouse Email Address *

Child 1 Full Name & SurnameFirstMiddleLast

Child 1 ID Number / Passport Number Child 1 Date Of BirthYYYY/MM/DD

Child 2 Full Name & Surname FirstMiddleLast

Child 2 ID Number / Passport Number Child 2 Date Of Birth YYYY/MM/DD

Child 3 Full Name & Surname FirstMiddleLast

Child 3 ID Number / Passport NumberChils 3 Date Of Birth YYYY/MM/DD

Child 4 Full Name & SurnameFirstMiddleLast

Child 4 ID Number / Passport NumberChild 4 Date Of Birth YYYY/MM/DD

Child 5 Full Name & SurnameFirstMiddleLast

Child 5 ID Number / Passport NumberChild 5 Date Of BirthYYYY/MM/DDDo you want to cover Extended Family? Eg Sister, Mom, Aunty, Grandmother EtcIf Yes, Please fill in the below informationSelect Policy For Extended Family Member 1Relationship of Extended Family MemberAunty, Gogo, Brother, Etc

Full Name & SurnameFirstMiddleLast

ID Number / Passport NumberDate of BirthSelect Policy For Extended Family Member 2Relationship of Extended Family Member 2

Full Name & Surname FirstMiddleLast

ID Number / Passport NumberDate of BirthSelect Policy For Extended Family Member 3 Relationship of Extended Family Member 3

Full Name & SurnameFirstMiddleLast

ID Number / Passport NumberDate of BirthI 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

I have paid my first installment with the Representative

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