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 61 OR OLDER
R44 R55
HOSPITAL CARE PLUS - VAT incl  
PRINCIPAL R90
ADULT R90
CHILD R30
ADDITIONAL PREMIUM PER PERSON
ENTRY 61 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.  

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 Plus: Please Select:

Do you have a Primary Care plan C dependants?
Do you have a Hospital Care plan B dependants?
Do you have a Hospital Care plan C dependants?
Do you have a Hospital Care Plus dependants?

Do you have any 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 :
Hospital Care Plus dependants :

Product Summary

The additional premiums at entry apply if an applicant has not had medical scheme or primary healthcare insurance coverage for 15 or more consecutive years of cover since the age of 35. These premiums may be waived if the applicant can demonstrate otherwise in writing.

Total

Enter Email

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 PREMIUM - 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


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