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Intermediary details
Intermediary Code: Parent: Name: Surname: Email Address:
Client Details
Protection of Personal Information Act (POPIA) Declaration By providing the information in this form on behalf of your client, consent is given to our fulfilment partner to establish contact in order to provide the necessary advice. Your client’s personal information will be stored in a secure encrypted manner and will not be sold or disseminated to any third party without their explicit consent.
Are you currently on a medical scheme? Yes No If Yes, which Scheme and Option: I have been a member since: Do you currently have a Health Care Broker? Yes No What is your family size? Adults Children Adult Dependents (over 21) Full Time Students Provide us with your family`s ages: Principal Spouse Adult Dependent Child 1 Child 2 Child 3 Child 4 Do you or your dependants use any chronic mediation? Yes No Do you want cover for day-to-day expenses? (eg. GP`s, Dentists, X-rays) Yes No Gross Income per month for Main Member? R0 – R5000 R5 001 – R8 000 R8 001+ Gross Income per month for Spouse? R0 – R5000 R5 001 – R8 000 R8 001+ Can we provide you with information regarding GapCover? Yes No Notes for specific requirements: Can we send you future communication on related news and products? Yes No
