Application

Cover for you, your spouse and your children. The choice is yours as to how to use the benefit. Control over your own plan, Up to R100 000 accidental death benefit for the plan holder and spouse.

First Step

Number:
Title:
Surname:
Full Names:
ID Number:
Address:
 
Email:
Tel No:
Mobile:
Marriage:
Employment:
PREFARED LANGUAGE (ANY OF THE SOUTH AFRICAN LANGUAGES)

Second Step

SPOUSE DETAILS If a Common Law spouse, please mark an X in the box

Surname:
Full Name:
ID Number:
CHILDREN DETAILS
1. ID/ DOB.
2. ID/ DOB.
3. ID/ DOB.
4. DOB.
5. DOB.
6. DOB.
7. DOB.
8. DOB.

Third Step

MEDICAL QUESTIONNAIRE

Have you or any of your dependants been diagnosed or treated in the last 2 years for:
1. Tuberculosis
2. HIV Aids
3. Heart condition
4. Cancer
5. Kidney failure
6. Have you or any of your dependants been bedridden for a period of more than 3 months?
Have you or any of your dependants received treatment from a doctor or clinic for the same illness on more than
Have you or any of your dependants been hospitalized for any illness during the past year?
If you answered "YES" to any of the above questions, please provide full details: