New Member Details Please fill in the below Name First Last Contact Number * Email Address * ID Number Address Address Line 1 * City * Province * Postal Code * Country * Asterio Plans Please choose your plan/s Combination Plans Green Combo - R798.00 Blue Combo - R1,183.00 Red Combo - R1,408.00 Dental Plan Bronze Dental Plan - R198.00 Gold Dental Plan - R517.00 Day to Day Only Green Day to Day - R398.00 Blue Day to Day - R839.00 Red Day to Day - R1,011.00 Hospital Plan Only - R586.00 Emergency Plan Only - R250.00 Hospital & Emergency - R690.00 Funeral Plans 10 000 Single Plan - R83.00 20 000 Single Plan - R124.00 30 000 Single Plan - R156.00 10 000 Family Plan - R106.00 20 000 Family Plan - R149.00 30 000 Family Plan - R210.00 Step Start Previous Next Add Spouse — Select — Yes No Spouse Details First Last ID Number Cover Combination Plan - R639.00 Day To Day Only - R318.00 Add Dependant/s — Select — Yes No 1st Dependent First Last Cover Combination Plan - R560.00 Day To Day Only - R278.00 2nd Dependent First Last Cover Combination Plan - R560.00 Day To Day Only - R278.00 3rd Dependent First Last Cover Combination Plan - R560.00 Day To Day Only - R278.00 Grand Total R 0 Step Start Previous Next Banking Details For debit order payments, we will attempt to deduct your premium on the debit order date you’ve selected, but may attempt to do so on another day if we are unsuccessful – or unable to attempt a deduction – on your chosen date. Name of Bank Account Number Debit Order Date Branch Code Account Type — Select — Cheque Savings Transmission Authorised signatory Bank Details for EFT & Bank DepositAcc name: Insure Group Managers | Bank: FNB | Acc type: Cheque | Acc no.: 62240945339 | Reference: Policy number I authorize monthly scheduled debit order payments to my bank account. My account will be debited the amount indicated on the product selected. I Agree Step Start Previous Next Medical Questions Please fill in the below Disorders or problems with organs/(s) e.g. heart or cardiovascular system, respiratory or lung, digestive system, stomach, gall bladder, pancreas or liver, kidneys, bladder or reproductive organs, nervous system or brain? Yes No Diabetes, sugar in urine, thyroid or other glandular or blood disorders. E.g. anemia, bleeding disorders, growth disorder, Cushing’s disease or Addison’s disease? Yes No Cancer, a growth or tumor of any kind including moles removed (malignant/benign)? Please specify if these were benign or malignant. Yes No Have you or any of your dependents ever had or been treated for a serious medical condition? If yes, kindly state. Yes No Have you or any of your dependents been hospitalized for any illness in the past 12 months? If yes, kindly provide with more info Yes No Textarea Do you have or any of your dependents have any disabilities? If yes, kindly name Yes No I have read and agree to the Terms and Conditions and Privacy Policy
