Online application

Product Selection & Personal Particulars
Premium Payment Details
Nomination of Beneficiaries
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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

PRIMARY CARE PLAN C BROCHURE

HOSPITAL CARE PLAN B & C BROCHURE

HOSPITAL CARE PLUS PLAN BROCHURE

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

Primary Care

Hospital Care

Product Selection Primary Care

Primary Care Plan C

Primary Care Plan C Pre-auth Waiver

Product Selection Hospital Care

Hospital Care Plan B

Hospital Care Plan C

Hospital Care Plus

Would you like to add dependants ?

Yes

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

Title

Initials *

Name *

Surname *

ID / Passport number

ID Number

Passport Number

Home / Work phone Number *

Cellphone Number *

Email Address *

Enter Email

Date of Birth *

Gender *

Commencement date has to start on the 1st of a calendar month (date cover is to commence)

Personal Particulars

Postal address same as physical address?

Yes

Physical Address *

Physical Address

Street Address

Building/Apartment/Suite #

Suburb

City

Zip/Postal

Postal Address *

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

Initials *

Name *

Surname *

Relationship

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

CHILD

Initials *

Name *

Surname *

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

ADDITIONAL ADULT

Initials *

Name *

Surname *

Relationship

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

ADDITIONAL CHILD

Initials *

Name *

Surname *

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

ADDITIONAL - 56 yrs+

Intials *

Name *

Surname *

Relationship

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

ADDITIONAL - 56 yrs+

Initials *

Name *

Surname *

Relationship

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

ADDITIONAL - 56 yrs+

Intials *

Name *

Surname *

Relationship

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

ADDITIONAL ADULT

Initials *

Name *

Surname *

Relationship

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

ADDITIONAL CHILD

Initials *

Name *

Surname *

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

ADDITIONAL - 56 yrs+

Initials *

Name *

Surname *

Relationship

ID Number

Passport Number

Date of Birth *

Gender

File Upload

Maximum file size: 134.22MB

If you are human, leave this field blank.

Online application – Register

Please select your product/s and complete the form to sign up

Product Summary

Personal Particulars

Dependants