Membership Application Please enable JavaScript in your browser to complete this form.Principle Member DetailsMr.Mrs.MissName *FirstLastID number *D.O.BMM/DD/YYYYCell number *AddressMarital StatusMarriedUnmarriedCategorySingle (Age 18-59) R60 monthlySingle (Age 60-74) R120 monthlyFamily (Age 18-59) R65 monthlyI agree to the R50 Registration fee: *I agreeR50 Entry Fee First Payment by:1st Day of the Month15th Day of the Month25th Day of the MonthEnd of the MonthSpouse Name (Leave blank if Unmarried)FirstLastSpouse ID number Spouse D.O.B MM/DD/YYYYSpouse Cell number 1st Dependent Name (Leave blank if no Dependants)FirstLast1st Dependent ID number / DOB2nd Dependent Name FirstLast2nd Dependent ID number / DOB 3rd Dependent Name FirstLast3rd Dependent ID number / DOB 4th Dependent Name FirstLast4th Dependent ID number / DOB 5th Dependent Name FirstLast5th Dependent ID number / DOB DECLARATION: I declare that at the time of joining this scheme, all members of my family and I are in good health and are free from any diseases that needed medical attention and were not treated for any serious condition for the last 6 (six) months. I also authorise the insurer to request the B.I. 1663 form (3 pages) for any member of my family covered by this policy should a claim arise. I declare that all information is correct and that any wilful misstatement will invalidate any claim to benefit from this policy. I acknowledge that the terms and conditions were explained to me and that I understand the terms and conditions of this policy and I undertake to abide by them. *I agree and give my permissionType Name for SignatureDateConsultant nameFirstLastSubmit
