health ROA – Health Step 1 of 3 33% Name* First Last Contact Information*Contact NumberEmail AddressID Number*Full Physical Address Street Address Address Line 2 City ZIP / Postal Code Do you require cover for your partner / family?* Yes No Partner and/or Family DetailsRelationshipDate of Birth Type of Cover Required* Hospital Plan Medical Aid Health Insurance MEDICAL AID: Unlimited hospital and savings for out of hospital expenses. HOSPITAL PLAN: No savings. HEALTH INSURANCE: Predefined amounts for Accident/Illness and GP’sHave you Currently or Previously had Cover?* Yes No This makes an impact on premium from companiesCover HistoryCompany and Member NumberStart DateEnd Date Very important if you are over 35 years oldDo any of you take any Chronic Medication?* Yes No Chronic MedicationConditionMedication Do any of you have any Pre-Existing Conditions?* Yes No Pre-Existing ConditionsCondition Do you have Gap Cover?* Yes No Who is your Gap Cover with? Approx. Monthly BudgetThis helps us to show you what you can get for this priceDo you belong to a Sport Club or Judo Club? No Yes Anything you would like us to be aware of or bring to our attention?Confirmation* The above information is true and correctBy selecting this box you confirm that all the information given on this form is true and correct. Advice, quotes and premiums are based on this information and is a record of the process undertaken by OneNet, a registered financial service provider FSP5471. If there is anything that you disagree with or do not understand please request further information.Signature
