MEMBERSHIP APPLICATION FORM Application Type Select Application Type: Individual Corporate Company Details Company Name: Contact Person: Date of Commencement: Personal Details Principal Member's Name in full: Identity Number: Postal Address: Home Address: Tel/Cell Number: E-mail Address: Date of Birth: Sex: Male Female Marital Status: Married Divorced Widowed Single Occupation: Banking Details Bank: Branch Code: Account Name: Account Number: Previous Medical Aid Membership Have you been a member of any Medical Aid in the past? Yes No Name: Number: Termination Date: Scheme Applied for Select Scheme: Diamond Express Scheme Platinum Scheme Gold Scheme Silver Scheme Dependents Add Dependent Medical History Please read carefully and complete all the required information by placing a tick in the correct box. If the answer to any of the questions is YES, please provide details in the box provided below in respect of the member or dependents applicable. Heart (Cardiac) Disease Circulatory Disorder Disease of the liver Disease of the airways/lungs Diseases of the Digestive system Diseases of Bladder/Kidney Neurological disorder Diseases of bone Endocrine Disorders Mental health Disorder Currently taking medication Other illness or factor Pregnant Please provide details for any conditions selected above: Declaration I declare that all false information in the above questionnaire or non-disclosure of any material information will render the membership null and void entirely. I have read and agree to the declaration statements Submit Application Please enable JavaScript for this form to work.
