EXPRESSION OF INTEREST IN MEDICAL COVER

1

Are you a South African Citizen?* This field is required.

YESNO

2

Do you or the persons you intend to cover live in the RSA?

YESNO

3

Does the intended policy payer have a valid South African Bank Account?

YESNO

4

Name* This field is required.

Prefix

First Name

Middle Name

Last Name

5

SA ID Number

6

Date of birth* This field is required.

Date

7

Phone Number* This field is required.

8

Phone Number

9

Email

example@example.com

Confirm Email

10

Your nearest town or city* This field is required.

We will use this to send you a list of Network Doctors once you take a policy

14

Time to call youIf no time we call between 08.00 and 17.00 weekdays

15

Should you for whatever reason not receive the validation SMS, do you give us permission to reply YES on your behalf?* This field is required.You should receive an SMS to which you should reply YES, however some clients have reported never receiving such SMS.

YESNO

16

Where did you hear about us?* This field is required.

17

Comments