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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 R150,000 per insured person per annum
(66 years & older) excluded.
R262.28  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
  • R150,000 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
Child Dependant 1
Child Dependant 2
Child Dependant 3
Child Dependant 4

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
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
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
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
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 Ronbel Supreme Gap
2.) Naptosa Ronbel 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