Proposal Form And Application Schedule

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RONBEL GAP PLUS SENIOR
APPLICATION FORM
Administered by
Ambledown Financial Services (Pty) Ltd Reg 2004/006271/07 FSP 10287
Underwritten by
Constantia Insurance Company Limited Reg 1952/001514/06 FSP 31111
Constantia Life and Health Assurance Co.Ltd. Reg 99/13922/06
NAPTOSA Membership No.
Unique Provincial Code
N
A
P
M
E
M
D
I
P
(P
M
)
ETAILS OF
NSURED
ERSON
RINCIPAL
EMBER
F
N
:
IRST
AME
S
:
URNAME
ID N
:
UMBER
M
A
&O
:
M
N
.:
EDICAL
ID
PTION
EMBERSHIP
O
P
A
P
A
HYSICAL
DDRESS
OSTAL
DDRESS
P
C
P
C
OSTAL
ODE
OSTAL
ODE
C
D
ONTACT
ETAILS
T
N
(W
)
F
:
EL
UMBER
ORK
AX
T
N
(H
)
C
:
EL
UMBER
OME
ELL
E-M
AIL
GAP COVER
PREMIUM PAYABLE
GAP PLUS SENIOR
Gap Cover, Co-Payment Cover, Co-payment for MRI & CT Scan Cover
225.00
No Maximum age of entry
Pfpm – Per family per month
R225.00
TOTAL PFPM PREMIUM DUE*
D
I
P
ETAIL OF
NSURED
ERSONS
R
N
S
A
ID N
ELATIONSHIP
AME
EX
GE
UMBER
S
POUSE
C
D
1
HILD
EPENDANT
C
D
2
HILD
EPENDANT
C
D
3
HILD
EPENDANT
C
D
4
HILD
EPENDANT
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 dependent on the Principal member’s medical aid. 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.
Completed forms can be emailed to
napadmin@memp.co.za
or Faxed to 086 723 4635 / Queries 041 363 7333
Gap Cover insured by Constantia Insurance Company Limited/Funeral Cover insured by Constantia Life and Health Assurance Company

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