Personal Details

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Select an Option

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Page 1 of 3

PERSONAL DETAILS

Policy Inception Date

ID / Passport Type

ID Number / Passport Number

Title

First Name

Last Name

Gender

Date of Birth

Age

Email Address

Cell Phone #

Residential Address

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Option Selection

Select Plan

Your Age

Total Monthly Cost

Cover is limited to the Policyholder and a maximum of 4 Dependants in total.

Dependants are:
Either an Adult or Child who is dependent upon the Policyholder for access to the benefits available within this policy.

Adult: A person over the age of 21 (twenty-one), except for a full-time student over the age of 21 (twenty-one) who is dependent on the Policyholder and approved by Us as eligible for membership of this policy.

Child: A Child is a person under the age of 21 (twenty-one), who is considered to be the Immediate Family of the Policyholder eligible for membership in terms of this policy. Cover as a Child can be extended to the age of 27 (twenty-seven) if they are full-time students. Documented proof of full-time studies is required annually.

Immediate Family: The Immediate Family is a defined group of relations, whether over or under the age of 21 (twenty-one) and determines which members of a Policyholder's family may join this policy.

The definition extends to those connected to the Policyholder in the following manner:

By birth, adoption, stepchildren or grandchildren or any other child who has been placed in the custody of the Policyholder and in respect of whom the Policyholder is liable for care and support.
Parents/stepparents, grandparents in respect of whom the Policyholder is liable for care and support.
Siblings, including half-siblings in respect of whom the Policyholder is liable for care and support.
A Spouse of a Policyholder as defined in this policy.
Any other relative, who at the Insurers discretion, qualifies for membership under this policy.

Spouse: A person who is a significant other, partner or non-marital partner of the principal member:

In a marriage or customary union recognised in terms of the laws of the Republic; or
In a union recognised as a marriage in accordance with the tenets of any religion; or
In a same sex or heterosexual union which the Underwriter is satisﬁed is intended to be permanent.

Option one is only selected.

Please refer to the terms and conditions in Policy Wording.

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SPECIFIC HEALTH QUESTIONS

Please tick Yes if the condition affects you or your dependants.

1. Have you/dependants been hospitalized in the past 4 mths?

Yes No

2. Do you/dependant expect to be hospitalised in the next 12 mths?

Yes No

3. Are you / dependents pregnant?

Yes No

4. Have you/dependants been on chronic meds in the past 24 mths?

Yes No

5. Is there any other info on you/deps which could affect the cover decision?

Yes No

6. Have you had any medical cover (medical insurance or medical aid) in the last 90 days?

Yes No

NOMINATED BENEFICIARY (Related To Accidental Death Benefit)

Title

First Name

Last Name

ID / Passport Type

ID Number/Passport

Date of Birth

Email Address

Cell Phone #

Work Phone #

Relationship to Policyholder

DEBIT ORDER AUTHORITY

Debit order on Main Member's account

Other

DEBIT ORDER DETAILS

Title

Account holder name

Account Number

Bank

Branch Code

Salary Day

Account Type

Debit order day

Payment instructions due in December may be debited against my/our account on:

INTERMEDIARY FEE AGREEMENT

with ID

I acknowledge that my intermediary / advisor is R&P Wealth Management with FSP number 46192, who is authorised to request GENRIC Insurance Company Limited (FSP number 43638) to collect an additional intermediary fee of R50 which is already included on selected plan for the services listed below.

To read the company's List of Services,

Signature and Date

Signature:

Signature Date:

I have read and agree to the , , and *