Principal Member Details
Title
Name
Surname
Contact Number
Fax Number (If Applicable)
Email
Province
Additional details
Are you currently on a medical scheme?  Yes   No
If Yes, which Scheme and Option:
I have been a member since:

Do you currently have a Health Care Broker?  Yes   No

What is your family size? Adults       Children   
Adult Dependents (over 21)       Full Time Students   
Ages:              

Do you or your dependants use any chronic medication?  Yes   No

Do you want cover for day-to-day expenses? (eg. GP’s, Dentists, X-rays)  Yes   No

Gross Income per month for Main Member?
 R0 – R5000   R5 001 – R8 000   R8 001+
Gross Income per month for Spouse?
 R0 – R5000   R5 001 – R8 000   R8 001+

Can we provide you with information regarding GapCover?  Yes   No

Would you prefer we communicate with you via telephone or email?  Telephone   Email

Notes for specific requirements:

Can we send you future communication on related news and products?  Yes   No
The following fields are required: