Online Application Form

Day1 Health Online Application Form

Once-off non-refundable activation fee of R200 applies.
Please note: Maximum age limit entries applicable to various plan options.

Personal Details (Principal Member)
Dependants to be covered
Your chosen network doctor
Nominated beneficiary
Day1 Health plan option
Medical Questions
Banking details

I warrant that I have been provided with all the intermediary, insurers and benefit details, or any additional information as I may have requested. I warrant that all details and facts provided herein are accurate and properly disclosed, even if completed by the intermediary or a representative on my behalf. I understand that the hospital stated benefits plan offered are risk benefits only and that there are no surrender values. Failure to pay premiums will result in benefits lapsing. In the event of any query regarding this policy or any claim in terms of this policy, I consent to the disclosure of any relevant information to the intermediary or any Day1 Health (Pty) Ltd official for the purposes of resolving the query. In the event of no nominated beneficiary, I agree that necessary burial costs will be paid directly, or to the person who paid for such costs. Thereafter any remaining benefit will be payable to the first claimant with reasonable title to claim any benefits. I acknowledge that the Day1 Health (Pty) Ltd Insured Health Plan is not a Medical Aid. I acknowledge that Day1 Health (Pty) Ltd and the Insurer, where applicable, reserve the right to accept or decline an application based on information provided at the time of application.

Copyright 2015 Day1 Health (Pty) Ltd | All Rights Reserved
Day1 Health (Pty) Ltd is an authorised Financial Services Provider. FSP No: 11319
Hospital Plan Underwritten by African Unity Life Limited (FSP 8447)
Day1 Health is a B-BBEE level contributor: Level Two (125% B-BBEE procurement recognition level) (1)(2)
Day1 Health complies with the principles of open enrolment, community rating and cross-subsidisation and does not discriminate or refuse membership on the basis of
race, age, gender, marital status, ethnic or social origin, sexual orientation, pregnancy, disability, state of health, geographical location or any other means of discrimination.