Surname ( Mr / Mrs / Ms ) (required)
Marital Status: (required) SingleMarriedDivorcedWidowed
Date of Birth (required)
Full Names (required)
Maiden Surname (if applicable)
Identity No. (required)
Postal Address
Tel
Email
Cell
Your present Occupation
Membership MISA MemberNUMSA memberNon-Union member
Name of Company (required) Street Address Tel
Email Postal Address Fax
The person to whom the death benefit shall be paid in the event of my death.
I hereby nominate Mr/Mrs/Ms (Surname) Marital Status: (required) SingleMarriedDivorcedWidowed Cell / Tel
Full Names I.D. No./Date of birth Relationship (Spouse, Son, etc.)
Address
I, the undersigned, solemnly declare that the above particulars are true and correct, and I agree to abide by all rules and regulations which are in force, or may be brought into force, from time to time. Consent in terms of Act 4 of 2013 (Protection of Personal Information Act). I hereby consent to MISA processing my personal information (as disclosed in this form), which includes my union membership information (if applicable), for purposes of the Motor Industry Sick, Accident and Maternity Pay Fund Agreement as well as the Rules issued in terms hereof. PLEASE NOTE
It is your responsibility to notify MISA if and when any of your information changes regarding your membership. This includes your personal and company details.
An 8 week waiting period for eligibility to any benefits applies to all Fund members from date of receipt of the first contributions by the Fund.
Application to be made within 26 weeks from death of a member and/or his/her dependants.
Signature
Date (required)
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