Solidariteit Application form
2019 APPLICATION FOR FAMILY 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.
Tel: 012 880 2230, Email: email@example.com
What you must do
1. Fill in the form.
2. Submit your application by emailing the form to us at firstname.lastname@example.org, 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 email@example.com
When you sign this application, you confirm that you have read and understood the terms and conditions of cover and agree to them.