ONLINE APPLICATION

ONLINE APPLICATION

  • Product Selection & Personal Particulars
  • Premium Payment Details
  • Nomination of Beneficiaries
  • Summary & Submit
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Please select your product/s and complete the form to sign up

PRIMARY CARE - VAT incl PLAN C
PRINCIPAL R410
ADULT R329
CHILD R130
ADDITIONAL PREMIUM PER PERSON
ENTRY 56 OR OLDER
R209
PLAN C Pre-auth Waiver R39
HOSPITAL CARE - VAT incl PLAN B PLAN C
PRINCIPAL R161 R192
ADULT R86 R107
CHILD R32 R44
ADDITIONAL PREMIUM PER PERSON
ENTRY 56 OR OLDER
R44 R55
HOSPITAL CARE PLUS - VAT incl
PRINCIPAL R90
ADULT R90
CHILD R30
ADDITIONAL PREMIUM PER PERSON
ENTRY 56 OR OLDER
R30

Hospital Plan B is a stand-alone product and cannot be taken up along with a Plan C product.

Hospital Plan C can be selected as an added benefit to your Primary Care Plan C product.

Hospital Care Plus can be selected as an added benefit to your Hospital Care Plan C product.

Product Selection

Product Selection Primary Care

Product Selection Hospital Care

Primary Care plan C: Please Select:
Hospital Care plan B: Please Select:
Hospital Care plan C: Please Select:
Hospital Care (Plan C & Plus): Please Select:
Primary Care Plan C Pre-auth Waiver: Please Select:

Would you like to add dependants ? (Primary Care plan C)
Would you like to add dependants ? (Hospital Care plan B)
Would you like to add dependants ? (Hospital Care plan C)
Would you like to add dependants ? (Hospital Care Plus & Hospital Care Plan C)
Would you like to add dependants ? (Primary Care Plan C + Pre-auth Waiver )

Would you like to add dependants ?

Primary Care plan C dependants :
Hospital Care plan B dependants :
Primary Care plan C & Hospital Care plan C dependants :
Hospital Care plan C dependants :
Primary Care Plan C + ( Pre-auth Waiver ) dependants :
Hospital Care (Plan C & Plus) dependants :

Product Summary

The additional premiums at entry will apply if an applicant has not had medical scheme or primary healthcare insurance coverage for 15 or more consecutive years since the age of 35.
These premiums may be waived if the applicant can demonstrate otherwise in writing. The applicant must provide proof of 15 credible years of cover at the time of joining and there should be no break in cover of 3 or more months when joining. The Hospital Care Plus product can only be taken with Hospital Care Plan C. The GP pre-auth waiver and Hospital Care Plus cannot be selected separately. The Hospital Care Plus product needs to be taken for all members on the policy.
Total

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Personal Particulars

Postal address same as physical address?
Physical Address
Street Address
Building/Apartment/Suite #
Suburb
City
Zip/Postal
Postal Address
Street Address
Building/Apartment/Suite #
Suburb
City
Zip/Postal
*Please upload clear copies of identity documents for all dependants, copy of the marriage certificate for a spouse dependant. Where applicable a physician report must be included to confirm disability of handicapped dependants.

Dependants

WE COVER: you, your spouse, eligible child and adult dependents for whom you are a parent or legal guardian of; your child dependant aged 20 or younger at a child dependant premium; your child dependant aged 21 to 26 at an adult dependant premium. Where applicable a physician report must be included to confirm disability of handicapped dependants. Proof of legal guardianship will be required in the form of court documentation.


ADULT

Maximum file size: 134.22MB


CHILD

Maximum file size: 134.22MB


ADDITIONAL ADULT

Maximum file size: 134.22MB


ADDITIONAL CHILD

Maximum file size: 134.22MB


ADDITIONAL - 56 yrs+

Maximum file size: 134.22MB


ADDITIONAL - 56 yrs+


Maximum file size: 134.22MB


ADDITIONAL - 56 yrs+

Maximum file size: 134.22MB


ADDITIONAL ADULT

Maximum file size: 134.22MB


ADDITIONAL CHILD

Maximum file size: 134.22MB


ADDITIONAL - 56 yrs+

Maximum file size: 134.22MB