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NAPTOSA Membership No.
BROKER DETAILS
Memp Financial Services (Pty) Ltd
BROKER CODE
MFS001
BROKER NAME
UNIQUE CODE
DETAILS OF INSURED PERSON (PRINCIPAL MEMBER)
First Name:
Surname:
ID Number:
Medical Aid & Option:
Membership No:
PHYSICAL ADDRESS
POSTAL ADDRESS
Postal Code:
Postal Code:
CONTACT DETAILS
Tel Number (Work):
Fax:
Tel Number (Home):
Cell:
E-Mail:
GAP COVER
PREMIUM PAYABLE
GAP SUPREME
Gap Cover, Co-Payment Cover, Co-Payment Cover for MRI & CT Scan, Sub-Limitation Cover, Cancer Cover, Dread Disease Cover, 6 Month Medical Scheme Premium Waiver and Costs incurred in casualty unit as a result of an accident limited to R10,000 per insured person per annum Overall Limitation R173,000 per insured person per annum
(66 years & older) excluded.
R350.00 pfpm
DREAD DISEASE EXCLUSIONS:
All tumors, which are histologically described as pre-malignant, as non-invasive or as cancer in situ.
All forms of lymphoma in the presence of any Human Immunodeficiency Virus.
Kaposi’s sarcoma in the presence of any Human Immunodeficiency Virus.
Any skin cancer other than malignant melanoma.
Cancerous cells that have not invaded the surrounding or underlying tissue
Early cancer of the prostate gland or breast. (Stage1 described as T1a, N0, M0, G1)
Specific condition
The Dread Disease Benefit terminates at the member reaching the benefit expiry age, or age 65.
PREMIUM WAIVER EXCLUSION:
Seniors (66 years & older) excluded.
Specific condition
The Premium Waiver Benefit terminates at the member reaching the benefit expiry age, or age 65.
Overall limitation
R165,000 per insured person per annum
FAMILY FUNERAL COVER
PREMIUM PAYABLE
Member / Spouse
Children (14-21 Years)
Children (7-13 Years)
Children (0-6 Years)
Stillborn
Maximum age of entry - 65
R30,000
R20,000
R 10,000
R 7,000
R 1,000
(Double the benefit if death is due to accidental causes)
R65.00 pfpm
Pfpm - Per family per month
(COMPULSORY FIELD - PLEASE COMPLETE) - TOTAL PER FAMILY PER MONTH PREMIUM DUE
GAP COVER PREMIUM
R
FUNERAL COVER PREMIUM
R
TOTAL PFPM PREMIUM DUE *
R
DETAIL OF INSURED PERSONS
Relationship
Name
Sex
Age
ID Number
Spouse
Male
Female
Child Dependant 1
Male
Female
Child Dependant 2
Male
Female
Child Dependant 3
Male
Female
Child Dependant 4
Male
Female
NOMINATED BENEFICIARY (FUNERAL COVER ONLY)
Name:
ID Number:
Contact Details:
MEDICAL QUESTIONNAIRE
1. Do you or any of your dependents suffer from any chronic or recurring illness or any other serious ailment? if “yes” please specify
No
Yes
Specify:
2. Have you or any of your dependents received treatment or advice by a medical practitioner in the last 12 months? If “yes” please specify
No
Yes
Specify:
Name of family’s general medical practitioner:
Contact Number:
3. Have you or any of your dependents been hospitalised during the last 12 months?
If ”yes” to the above please specify the condition for which hospitalisation was necessary
No
Yes
NAME
DATE HOSPITALISED (DDMMYYYY)
REASON FOR HOSPITALISATION
4. Do you or any of your dependents expect to be hospitalised during the next 12 months?
If ”yes” to the above please specify the condition for which hospitalisation was necessary
No
Yes
NAME
DATE HOSPITALISED (DDMMYYYY)
REASON FOR HOSPITALISATION
DEBIT ORDER AUTHORISATION
DEBIT ORDER DATE
PREFERRED
1ST
15TH
20TH
25TH
(* THE DATE THAT THE DEBIT ORDER PAYMENT IS SUCCESSFULLY RECEIVED)
DEBIT ORDER AUTHORISATION
ACCOUNT HOLDER:
BANK:
ACCOUNT NUMBER:
BRANCH:
BRANCH CODE:
ACCOUNT TYPE:
By completing this electronic online application form and pressing the submit button I am bound by the terms and conditions of the respective Master Policy Document.
1.)
Naptosa Supreme Gap
2.)
Naptosa Family Funeral Cover
3.)
Debit Order Authorisation
I accept that by submitting this application that I have made an informed decision and that I agree to the monthly debit order amount as per this email application.
I accept these terms and conditions