+27 860 102 936 info@medgaponline.co.za

2020 APPLICATION FOR PENSIONER COVER

Thank you for deciding to apply for gap insurance cover with MedGap, underwritten by Guardrisk Insurance Company Limited (Reg. 1992/001639/06, FSP No. 75). This document is an application form for cover. Please complete the form accurately and completely in order that we may process your application.

Contact us

Tel: 012 880 2230, Email: info@medgaponline.co.za

What you must do

1. Fill in the form.
2. Submit your application by emailing the form to us at new@medgaponline.co.za, with your medical aid membership certificate and proof of previous gap cover (if you are moving your cover from another insurer to us).

Once you have submitted your application form:

• If any details are missing or we need more information, we will contact you.
• We will activate your membership and we will email you a confirmation of cover, along with your policy wording.
• If you do not hear from us 2 weeks after sending us your application, please contact us on 012 880 2230 or email new@medgaponline.co.za

When you sign this application, you confirm that you have read and understood the terms and conditions of cover and agree to them.

2020 APPLICATION FOR PENSIONER COVER
  • About yourself
  • Contact details
  • Cover Options
  • Previous Gap
  • Your Health
  • Beneficiary details
  • Banking Details
  • Brokers Details
  • Deceleration
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TELL US WHO IS COMPLETING THIS FORM

Please read and initial each declaration under Client / Applicant declaration and consent
Please read and initial each declaration under Broker declaration and consent

TELL US ABOUT YOU

Maximum upload size: 3MB
All dependants must reflect on your medical aid certificate, be named on your cover with us and must be covered on your medical aid at the time of a claimable event.