+27 860 102 936 info@medgaponline.co.za
Bonitas application form

2022 APPLICATION FOR FAMILY COVER / MILLENNIAL / PENSIONER

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.

2022 APPLICATION FOR FAMILY COVER / MILLENNIAL / PENSIONER - Bonitas
  • About yourself
  • Cover Options
  • Previous Gap Cover
  • About your Health
  • Beneficiary details
  • Banking Details
  • Brokers Details
  • Declaration and Consent
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PLEASE INDICATE WHICH COVER YOU ARE APPLYING FOR:

Choose option below

TELL US WHO IS COMPLETING THIS FORM (SECTION APPLICABLE TO FAMILY COVER, MILLENNIAL AND PENSIONER)

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

YOUR CONTACT DETAILS (SECTION APPLICABLE TO FAMILY COVER, MILLENNIAL AND PENSIONER)

Postal address
City
State/Province
Zip/Postal
Physical address
City
State/Province
Zip/Postal

DEPENDANTS

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. (NOT APPLICABLE TO MILLENNIALS AND PENSIONERS)
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