Get Started Home Signup Signup Today! First Name *SurnamePhoneMobile numberEmail *AgeI agree to the terms and conditions.Before we start: We might need the following documents from you, so please have them ready: ID Document Proof of banking Proof of address SA ID NumberTax NumberPreferred LanguagePreferred LanguageEnglishAfrikaansEthnic GroupEthnic GroupAfricanColouredWhiteOtherMarital StatusMarital StatusMarriedNot marriedPlease selectPlease selectSingleDivorcedWidowStreet Address *SuburbCityProvincePostal CodePostal address is the same as residential?Postal address is the same as residential?YesNoPostal addressCityProvincePostal CodeWould you like to add dependants?Would you like to add dependants?YesNoAdd dependantsFull name of dependantIs dependent a SA Citizen?SA Citizen?YesNoDependant ID numberPassport NumberDependant date of birthRelationship with dependantDo you have previous medical cover?Do you have previous medical cover?YesNoMedical Cover InformationName of Medical AidMembership numberDate joinedDate leftHave you or any of your dependants sought any advice, been diagnosed with or been treated for any conditions in the last 12 months? Examples: Chronic illness or ailment Pregnancy Bronchitis COVID-19 SpecifySpecifyYesNoDiagnosisHas this beneficiary been hospitalised in the last 12 months?Has this beneficiary been hospitalised in the last 12 months?YesNoHas this beneficiary received treatment in the last 12 months?Has this beneficiary received treatment in the last 12 months?YesNoDate of last treatment received*Name of medication / treatmentDosageName of treating healthcare providerContact number of treating healthcare providerSubmit my info
