Get Gap Cover

Medical Scheme Membership Number*
Name of Medical Scheme*
Medical Scheme Option*
Previous Gap Cover
Date Joined
Date Terminated
Required Inception Date

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Principal Insured Details
Name*
Title First Last
ID Number / Passport*
Date of Birth*
Email*
Home Phone Number
Work Phone Number
Cellphone Number*
Residential Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is your Postal Address the same as your Residential Address?
Postal Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Spouse Details
Are you married in community of property
Name
Title First Last
ID Number / Passport
Date of Birth
Email
Home Phone Number
Work Phone Number
Cellphone Number
Dependants
Dependents are:
- Spouse and/or dependant children up to the age of 21 years
- Students up to the age of 27 (please prove full-time enrolment)
- Adopted/foster child (please attach documentary proof)
- Provide studency proof or medical certificate if you are on the same medical aid
How many dependents do you want to add?*
Dependent 1
Name
First Last
Relationship to Applicant
ID Number / Passport
Date of Birth
Dependent 2
Name
First Last
Relationship to Applicant
ID Number / Passport
Date of Birth
Dependent 3
Name
First Last
Relationship to Applicant
ID Number / Passport
Date of Birth
Dependent 4
Name
First Last
Relationship to Applicant
ID Number / Passport
Date of Birth
Dependent 5
Name
First Last
Relationship to Applicant
ID Number / Passport
Date of Birth
Dependent 6
Name
First Last
Relationship to Applicant
ID Number / Passport
Date of Birth

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Specific Health Questions
The following questions are related to the policyholder and or any beneficiaries or dependents on the policy.
1. Have you been admitted to hospital in the last 4 months?
Applicant/Dependent Name
Disorder
Medication
Date Diagnosed
2. Are expecting a hospital admission or aware of any conditions or Illness that would require treatment in the next 12 months?
Applicant/Dependent Name
Disorder
Medication
Date Diagnosed
3. Are you or any of your dependents currently pregnant?
Applicant/Dependent Name
Disorder
Medication
Date Diagnosed
4. Have you taken or are currently taking chronic medication in the past 24 months?
Applicant/Dependent Name
Disorder
Medication
Date Diagnosed
5. Have you been on gap cover before and / or have had a gap claim? If yes, who was the provider?
Applicant/Dependent Name
Disorder
Medication
Date Diagnosed

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Declaration by Applicant
I, the undersigned, hereby declare:
1. That to the best of my knowledge and belief the information provided in connection with this application whether in my own handwriting or not, is true and I have not withheld any material facts which are known to me. (A material fact is likely to influence the assessment of this application by Sirago Underwriting Managers (Pty) Ltd. If you are in any doubt as to whether a fact is material or not, you should disclose it.)
2. That I understand that any relevant material fact omitted in this proposal form may lead to Sirago Underwriting Managers (Pty) Ltd not meeting claims, should the omitted fact have been of such importance that the risk may not have been accepted in the first instance, in terms of the policy. This may lead to the cancellation of this policy or rejection of claims without refund of premiums.
3. That I understand that this is an Accident and Health policy with stated benefits in terms of the Short-term Insurance Act 53 of 1998 and not a Medical Scheme product.
4. The sharing of claims information and underwriting information by Insurers is essential to enable the insurance industry to underwrite policies, assess risks fairly, reduce the incidence of fraudulent claims and protect the public interest in terms of limiting excessive premium increases. You hereby waive any right to privacy of any insurance information provided by you or on your behalf, in respect of any insurance policy or claims you lodge. You also consent to this information being disclosed to any other insurance company and/or verified against other legitimate source or a database.
5. I specifically consent to Sirago Underwriting Managers (Pty) Ltd contacting my current Medical Scheme and/or medical practitioner to verify any medical details as provided in my application form. I further consent to such information being disclosed to Sirago Underwriting Managers (Pty) Ltd for purpose of verifying the disclose as provided on my application form.
6. That I will advise Sirago Underwriting Managers (Pty) Ltd of any changes to my health state between the point of application and actual inception of my policy.
7. As part of our claims validation process we used the services of a contracted third party in order to authenticate medical scheme membership, plan option type, relevant beneficiaries and agreed medical scheme option tariffs amongst other relevant information to validate the claim.
8. We reserve the right to call for additional information of a clinical nature. In the event that Sirago requests a PMA (Post Medical Assessment) from your doctor as part of the claims assessing and authentication process
9. I authorise Sirago Underwriting Managers to negotiate with service providers on my behalf for my medical claims and or bill and pay the provider direct.
10. By agreeing to the terms of this consent form, I expressly consent to the processing of my information for marketing purposes and know & understand that by agreeing to same that I may on occasion, receive marketing materials in the form of sms and / or emails and the like from Sirago Underwriting Managers (Pty) Ltd.
Signature of Policy Holder

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Option Selection
Ultimate Gap Cover
Plus Gap Cover
Gap Assist Cover
Gap-Lite Cover
Gov-Gap Cover
Exact Cover
Exact with Gap and Co-pay Cover

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Nominated Beneficiary (related to death benefits and/or premium waivers)
Name
Title First Last
ID Number / Passport
Date of Birth
Email
Home Phone Number
Work Phone Number
Cellphone Number
Relationship to main member
The Premium waiver benefit consists of two sub-benefit categories and is only applicable to active dependents who on the Sirago policy at the time of death or Total Permanent Disability

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Debit Order Details
Name of Account Holder
First Last
Account Number
Bank
Account Type
Debit order day
- 1st
- 7th
- 15th
- 25th
- 31st
- Other
Other debit order day
I hereby instruct and authorise you to draw against my bank account the amount necessary for the payment of my monthly premium due in respect of the above-mentioned insurance, without prejudice to the rights of Sirago Underwriting Managers (Pty) Ltd. I further authorise you to increase the amount in the terms of the policy from time to time and authorise my bank to effect payment.
Signature
Date
I/we certify that the above bank details are correct. If these banking details have not been provided accurately, or if the details change at any time in the future and I/we fail to notify such changes or if payments are not made in accordance with the Debit Order Instruction, the responsibility of payment will rest with me/us.
Premiums are payable on a monthly basis by debit order. If two or more debit orders are returned, Sirago Underwriting Managers (Pty) Ltd will not be held liable should the policy be automatically terminated, or should claims incurred during this period of suspension not be paid. I acknowledge that any fees and charges levied by the bank on account of the debit order or any debit order payments which may be rejected for any reason whatsoever will be for my account.

*If the facility is in the name of a Company, Close Corporation, Trust or Association the full names of such entity and the capacity of the signatory must be reflected. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the very next ordinary business day. Payment instructions due in December may be debited against my account on
December Debit Date

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Debit Order Details for Refunds
Are your banking details the same as the banking details for refunds?*
If No, please fill in the details below
Name of Account Holder
First Last
Account Number
Bank
Account Type
Signature
Date

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Broker Details
Do you have a Broker?*
Intermediary Group
Intermediary Code
Sales Person
Sales Code
Telephone Number
Cellphone Number

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Application form for Individuals and Families

Step 1 of 11

Principal Insured Details

Spouse Details

Dependants

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5

Dependent 6

Specific Health Questions

Declaration by Applicant

Option Selection

Nominated Beneficiary (related to death benefits and/or premium waivers)

Debit Order Details

Debit Order Details for Refunds

Broker Details

Statistics

Contact

Social Networks

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HOW CAN WE
HELP YOU?

WE ARE HERE TO HELP YOU.

Get Gap Cover

Application form for Individuals and Families

Step 1 of 11

Principal Insured Details

Spouse Details

Dependants

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5

Dependent 6

Specific Health Questions

Declaration by Applicant

Option Selection

Nominated Beneficiary (related to death benefits and/or premium waivers)

Debit Order Details

Debit Order Details for Refunds

Broker Details

Statistics

Contact

Social Networks

menu

HOW CAN WEHELP YOU?

WE ARE HERE TO HELP YOU.

HOW CAN WE
HELP YOU?