Medical Cash Plan

1 of 4

Personal
Details
2 of 4

Next of Kin
3 of 4

Desired Cover
4 of 4

Responsible Person

personal detail

*Title

Please select a ID type

*First Name

Please enter a first name

*Surname

Please enter a surname

*Date of Birth

Please enter a date of birth

*Gender

Male

Female

Please select a gender

*Marital Status

Married

Single

Separated

Divorced

Please select a marital status

*ID Type

Please select a ID type

*ID Number

Please enter a id number

Contact Details

*E-mail address

Please enter a e-mail address

*WhatsApp Number

Please enter a whatsapp number

Cellphone Number (If different from WhatsApp)

Please enter a cellphone number

ADDRESS DETAILS

*Address Line 1

Please enter a address line 1

*Address Line 2

Please enter a postal address line 2

*City

Please select a city

Next of kin

*First Name

Please enter a first name

*Surname

Please enter a surname

*Date of Birth

Please enter a Date of Birth

*Relationship

Please select a Relationship

Next of kin Address Details

*Address Line 1

Please enter a address line 1

*Address Line 2

Please enter a address line 2

*City

Please select a city

Next of kin Contact Details

*E-mail

Please enter a e-mail

*Cellphone

Please enter a cellphone

Landline

Please enter a landline

AVAILABLE PLANS

	Children Per Child (18 years or 23 years & below if still in school)	Adults Per Adult (65 years & below)
	Basic Plan (Does not cover Pre-existing Conditions or Maternity)
Annual Global Limit	US$ 450 000.00	US$ 1 050 000.00
Daily Benefit	US$ 7 500.00	US$ 15 000.00
Monthly Premium	US$ 375.00	US$ 750.00
	Basic Plus Plan (Covers Pre-existing Conditions)
Annual Global Limit	US$ 750 000.00	US$ 1 500 000.00
Daily Benefit	US$ 12 500.00	US$ 30 000.00
Monthly Premium	US$ 500.00	US$ 1 375.00
	Executive Plan (Covers Maternity & Pre-existing Conditions)
Annual Global Limit	US$ 1 200 000.00	US$ 1 800 000.00
Daily Benefit	US$ 25 000.00	US$ 45 000.00
Monthly Premium	US$ 1 250.00	US$ 2 000.00

FAMILY / OTHER DEPENDENT DETAILS

Add a Product (Dependent)

Basic Plan (Does not cover Pre-existing Conditions or Maternity)

Basic Plus Plan (Covers Pre-existing Conditions)

Executive Plan (Covers Maternity & Pre-existing Conditions)

Medical History

*Have you been scheduled for any medical or surgical treatment within a period of 12 months?

Yes

Please select a medical or surgical treatment