Please note that if you are married or in a permanent relationship then the older one of you and your spouse / partner must be the main member and that person's details must appear below next to Surname, First Names, etc. unless the two spouses/ partners fall into the same age category, eg both are in age group 14-59 or 60-74. This is not the case with our legal cover product where any one of the parties can be the main member. Click here if you want to view our legal cover application form.
Click here to download our legal cover application form or continue with this online application if you are the main member applying for this policy.
Child' includes your biological children and those legally adopted by you. Children can be covered under your policy if they are under 21 years old and still dependent on you or up to age 25 if they are still studying. If not then they must take out their own policy. New born children can be added to your policy at any time. You can select Extended Family Members (father, mother, brother, sister, in-laws, etc) to include in your policy further down below.
Extended Family (Optional)
Below you have the option to take out cover for any other family members including your parents, parents-in-law, brothers, sisters, aunts, uncles, etc.Please note that Extended Family must be added before you pay your first premium and cannot be added to your policy after that.
Optional Additional Extended Family up to Age 13
(Monthly Premiums Payable: R3000,00 = R15,00 ; R7000,00 = R25,00 ; R10000,00 = R35,00)
Have you or any of the dependants/extended family above suffered from any of the following in the past?
Have you or any of your dependents been bedridden for a period of more than 3 months?
Have you or any of your dependents received treatment from a doctor or clinic for the same illness on more than
one occasion during the past 2 years?
Have you or any of your dependents been hospitalised for any illness during the past 2 years?
If you answered Yes to any of the questions above, please provide us with full details.