Sanlam Proposal - OneNet Health & Insure

Sanlam Proposal Request

Name(Required)

First Last

Contact Number(Required)

ID Number(Required)

Email(Required)

Full Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Current Medical Aid Company(Required)

What Plan are you on?

Medical Aid Number(Required)

Are you applying as a SINGLE or FAMILY(Required)

Would you like to ADD the MEDICLINIC Extender Benefit?

Key Benefits: Cashless Co-Pays, Specialist Benefit, Casualty Illness Benefit, Cancer Agreed Benefit

Yes – Additional Premium SINGLES Under 60 – R55.00

Yes – Additional Premium FAMILY Under 60 – R123.00

Yes – Additional Premium for Over 60 years old

Banking Details for Debit Order(Required)

Bank Name

Branch Code

Account Number

Inception Date of Policy (MUST be 1st Day of Month))(Required)

Debit Order Date(Required)

1st, 7th, 15th, 25th ONLY

Do you or any of your eligible dependents have any existing medical conditions?(Required)

What are the medical conditions?

Have you or any of your eligible dependents been advised of or are personally aware of any diagnosis, illness or condition (including pregnancy and dentistry) that could result in hospitalisation and/or surgery?(Required)

What are the medical conditions?

Do you or any of your eligible dependents currently receive any form of ongoing treatment or monthly medication?(Required)

What is the Treatment or Medication?

Have you had Gap Cover before?(Required)

Signature(Required)

Today's Date