Membership Application Form

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Day to Day Only

Value Plus Hospital Plan

Platinum Plan

Senior Plan 55+

Value Plus Plan

Executive Plan

Senior Comprehensive Plan

Personal Details (Principal Member)

Dependants to be covered

Full Name

ID Number

Gender

DOB

Your chosen network doctor

Main Member

Spouse

Child 1

Child 2

Child 3

Child 4

Doctor Name

Telephone Number

Nominated beneficiary

Medical Questions

1. Are you or any of your dependants on any form of chronic medication?

2. Are you or any of your dependants receiving treatment for any other medical condition other than a chronic condition?

3. Are you or any of your dependants receiving treatment for any dental condition?

4. Are you pregnant or is there a possibility that you may be pregnant?

5. Have you or any of your dependants undergone any major operations?

6. Have you or any of your dependants ever been admitted into hospital?

7. Are you or your spouse a member of a medical scheme or hospital plan?

8. Do any of your dependants answer yes to any of these questions?

Banking details

Acknowledgement

I warrant that I have been provided with all the intermediary, insurer's and benefit details or any additional information that 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. Any remaining benefit will, thereafter, be payable to the first claimant with reasonable title to claim any benefit. I acknowledge that the Day1 Health (Pty) Ltd Insured Health Plan is not a Medical Aid.

Acknowledgement Page

Name Price

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