I, the undersigned, hereby declare and warrant any and all information supplied herein to be true and complete. I am aware and understand that any non-disclosure o r misrepresentation of information which 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 I am applying for, meets my needs and feel that I have the necessary information in order to make an informed decision in respect of the purchase thereto. I further confirm that I have been informed of the terms and conditions of this product. I must have 6 receipts to claim for death. Have you cancelled, or do you intend to cancel any existing policy in order to take out this one? YES / NO Did you have any uninterrupted cover for the past three (3) months? YES / NO The financial advisor has provided me with satisfactory details of his experience and assisted me to understand and desire these benefits. I undertake to abide by the terms and conditions contained herein. The following have been explained to me in detail by the financial advisor: the benefits, premiums, commission and fees payable, disclosures and exclusions, which I understand could limit my right to a benefit in terms of the policy. I understand that there are certain costs which apply to this policy. I understand that I have the right to cancel this policy within 30 days after receipt of the policy document.