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Home
About
Services
Physical Asset Insurance
Medical Cover
Life & Disability insurance
Investments
Bespoke financial advice
Media
Contact
Home
About
Services
Physical Asset Insurance
Medical Cover
Life & Disability insurance
Investments
Bespoke financial advice
Media
Contact
Menu
Home
About
Services
Physical Asset Insurance
Medical Cover
Life & Disability insurance
Investments
Bespoke financial advice
Media
Contact
Medical aid with hospital cover & medical savings
Capture your details and we’ll get an expert to respond with some options and guidance for you.
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
Personal Information
First Name
Surname
ID Number
Nationality
Cellphone Number
Email Address
Are you currently on medical aid?
Please select…
Yes
No
Name of Scheme
Number of years covered
Have you previously been on medical aid?
Please select…
Yes
No
Name of Scheme
Number of years covered
Are you currently on GAP?
Please select…
Yes
No
Name of Scheme
Do you require GAP Cover?
Please select…
Yes
No
Do you have a dependant?
Please select…
Yes
No
Full Name and Surname
Relationship
ID Number
Do you have another dependant?
Please select…
Yes
No
Full Name and Surname
Relationship
ID Number
Do you have another dependant?
Please select…
Yes
No
Full Name and Surname
Relationship
ID Number
Additional Information
Do you earn a gross salary of less than R13 800 pm?
Please select…
Yes
No
Please state amount (personal)
Please state amount (spouse)
How would you describe your current general health?
Have you or any of your dependants ever been diagnosed with and/or treated for cancer?
Please select…
Yes
No
Have you or any of your dependants been hospitalised in the last 5 years or have any planned procedure in the immediate future (within 6 months)?
Please select…
Yes
No
Do you take daily medication to treat a chronic condition? (If yes, please state the condition & medication used)
Do any of your dependents take daily medication to treat a chronic condition? (If yes, please state which dependent, the condition & medication used)
Any other pre-existing medical issues?
Name of preferred hospital near your home?
Emergencies are covered at any hospital BUT are you happy to only use certain hospitals for planned procedures if it reduces your monthly premium?
Please select…
Yes
No
Would you prefer a medical aid with a rewards programme? (e.g. Vitality / Multiply)
Please select…
Yes
No
Terms and conditions
By ticking, you are confirming that you have read, understood and agree to
Life Current terms and conditions.
Submit