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I the undersigned, hereby declare and warrant all information supplied herein, to be true and correct. I am aware that any non-disclosure or misrepresentation of information, which is material to the determination of the risk by The Underwriter, may lead to the policy being declared null and void in which case all premiums paid will be forfeited. I am certain that the product which I am applying for meets my needs and feel that I have all the necessary information in order to make an informed decision in respect of the purchase thereof. The Terms and Conditions and the Intermediary Disclosure Document were made available and explained to me. Acceptance of this policy is subject to verification done by Safrican in terms of the Financial Intelligence Centre Act (Act 38 of 2001). DOROTIAN FUNERAL SERVICES shall not be liable for any amount until it has accepted this application and this policy if in force. If any person is over the age limit when joining, the claim will be repudiated and premiums refunded. I understand that this product is offered to me on a non-advice basis, and that should I need to I may contact DOROTIAN FUNERAL SERVICES offices for assistance.