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Administered by Ambledown Risk and Underwriting Managers (Pty) Ltd Reg 2004/006271/07 FSP 10287 Ronbel 198(Pty) Ltd Reg 2007/031620/07 FSP 37365
Underwritten by Constantia Insurance Company Limited Reg 1952/001514/06
Constantia Life and Health Assurance Co. Ltd. Reg 99/13922/06

Gap Policy No. Funeral Policy No.
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:

PLEASE BE ADVISED THAT I WISH TO CANCEL MY EXISTING GAP AND/OR FUNERAL POLICY AND MIGRATE TO THE FOLLOWING:
GAP COVER PREMIUM PAYABLE
*IMPORTANT NOTE: Should either the Principal Member or any of their dependents ever have been diagnosed or treated for any form of cancer, there will be a permanent exclusion for that person on the Cancer Cover benefit. However, the member or dependents still qualify for the other gap products.
GAP SUPREME
(Maximum age of entry - 70)
Gap Cover, Co-Payment Cover, MRI & CT Scan Cover, Co-Payment Cover for MRI & CT Scan, Sub-Limitation Cover, Cancer Cover, 6 Month Medical Scheme Premium Waiver and Costs incurred in casualty unit as a result of an accident. R225.00 pfpm
NOTE: for Senior application (over 70 years) – please contact the office on 041 363 7333

FAMILY FUNERAL COVER Maximum age at entry 65 PREMIUM PAYABLE
Member / Spouse
Children (14-21 Years)
Children (7-13 Years)
Children (0-6 Years)
Stillborn
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    
(NOTE: THIS SECTION MUST BE COMPLETED) GAP COVER PREMIUM R  
FUNERAL COVER PREMIUM R  
TOTAL PREMIUM R  


DETAIL OF INSURED PERSONS
Relationship Name Sex Age ID Number
Spouse
Child Dependant 1
Child Dependant 2
Child Dependant 3
Child Dependant 4

Eligible child means a child who is factually (by way of natural/biological child born of or stepchild or legally adopted child or placed under the foster care of the Principal Insured member) or financially dependent on the Principal Member and who has not attained the age of twenty one (21) and who is not already insured under this policy or any other insurance issued by the Company providing similar cover. This age may be extended to twenty five (25) in respect on an unmarried child who is a full time student for Gap Cover and to twenty six (26) for Funeral Cover. There will be no age restriction for children who are either mentally or physically incapacitated from maintaining themselves always provided that the children are wholly dependent on the Principal Insured Member for support and maintenance. A child shall only be accepted for cover if such child is covered in terms of the Principal Insured Member’s medical aid scheme.

Extended family - Should you have extended family on your medical scheme they are not covered on this policy. They can apply as the principal member at the same Naptosa Rates.


NOMINATED BENEFICIARY (FUNERAL COVER ONLY)
Name: ID Number:
Contact Details:

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 Ronbel Supreme Gap
2.) Naptosa Ronbel Family Funeral Cover
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 

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