Principal Member Details
Contact Number
Fax Number (If Applicable)
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   

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: