Medical Cash Plan

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Personal
Details
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Next of Kin
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Desired Cover
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Responsible Person

personal detail

*Title

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*First Name

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*Surname

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*Date of Birth

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*Gender

Male

Female

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*Marital Status

Married

Single

Separated

Divorced

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*ID Type

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*ID Number

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Contact Details

*E-mail address

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*WhatsApp Number

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Cellphone Number (If different from WhatsApp)

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ADDRESS DETAILS

*Address Line 1

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*Address Line 2

Please enter a postal address line 2

*City

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Next of kin

*First Name

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*Surname

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*Date of Birth

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*Relationship

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Next of kin Address Details

*Address Line 1

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*Address Line 2

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*City

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Next of kin Contact Details

*E-mail

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*Cellphone

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Landline

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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

Legal insurance

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Funeral Cash Plan

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