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• 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 - R860.00 Blue Combo - R1,270.00 Red Combo - R1,515.00
  • Dental Plan
    Bronze Dental Plan - R215.00 Gold Dental Plan - R556.00

  • Day to Day Only
    Green Day to Day - R430.00 Blue Day to Day - R900.00 Red Day to Day - R1,090.00 Hospital Plan Only - R630.00 Emergency Plan Only - R270.00 Hospital & Emergency - R740.00

  • Funeral Plans
    10 000 Single Plan - R89.00 20 000 Single Plan - R133.00 30 000 Single Plan - R168.00 10 000 Family Plan - R114.00 20 000 Family Plan - R160.00 30 000 Family Plan - R226.00
Step Start
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Add Spouse
— Select — Yes No
Spouse Details
First
Last
ID Number
Cover
Combination Plan - R687.00 Day To Day Only - R340.00
Add Dependant/s
— Select — Yes No
1st Dependent
First
Last
Cover
Combination Plan - R600.00 Day To Day Only - R340.00
2nd Dependent
First
Last
Cover
Combination Plan - R600.00 Day To Day Only - R340.00
3rd Dependent
First
Last
Cover
Combination Plan - R600.00 Day To Day Only - R340.00
Grand Total
R 0
Step Start
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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
[su_box title="Bank Details for EFT & Bank Deposit" style="default" box_color="#333333" title_color="#FFFFFF" radius="3" class="" id=""]Acc name: Insure Group Managers | Bank: FNB | Acc type: Cheque | Acc no.: 62240945339 | Reference: Policy number[/su_box]
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
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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
 
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