Click the SAVE button to save your progress if you have to rush off, but don’t forget to come back to us because your application will only reflect on our side if it’s fully completed and submitted.
CREATE YOUR PROFILE
Speak with your HR Representative or Broker about the Corporate Gap Cover and/or Corporate Health Insurance option available to you as an employee, as well as the waiting periods and terms and conditions of cover before submitting your application form.
Based on the discussion you've had with your HR Representative or Broker, please select the type of application relevant to your profile:
PRINCIPAL INSURED DETAILS
Let us know who the existing principal insured person is and we’ll swop your status from dependant to principal insured on your own policy.
And now... it's your turn.
EMPLOYER GROUP SCHEME DETAILS
BROKER DETAILS
Broker Details
YOUR DETAILS
Medical Aid Details
One Gap Cover policy covers you, your spouse and all the dependants registered on both your and your spouse’s medical aid plans.
One Gap Cover policy covers you, your spouse and all the dependants registered on both your and your spouse's medical aid plans, subject to approval from your employer.
One Health Insurance policy covers you, your spouse and all your child dependants as long as you're their parent or legal guardian.
Children aged 20 years or younger pay child dependant premiums on a Health Insurance Policy only. Children aged 21 years or older pay adult dependant premiums if they are full-time students and proof of financial dependency is submitted every year. We accept proof from the educational facility or stamped copies of your child’s bank account statements of the past 3 months.
One Health Insurance policy covers you, your spouse and all your child dependants as long as you're their parent or legal guardian, subject to approval from your employer.
Children aged 20 years or younger pay child dependant premiums on a Health Insurance Policy only. Children aged 21 years or older pay adult dependant premiums if they are full-time students and proof of financial dependency is submitted every year. We accept proof from the educational facility or stamped copies of your child’s bank account statements of the past 3 months.
Add a Dependant
Dependant {binding ItemNumber}
Medical Aid Details
If you haven’t selected a Gap Cover product, ignore and click Next.
GAP COVER OPTIONS
GAP COVER OPTIONS
If you’re an individual aged 65 or older applying for cover just for yourself, we’ll cover you under a 65+ individual option. If you apply for cover as a family, and either you or one of your dependants is 65 years or older, you and your family will be covered under a 65+ family option.
We'll automatically adjust your policy premium if you've selected an incorrect policy premium category.
INDIVIDUALS 64 OR YOUNGER
ACCESS OPTIMISER
FAMILIES 64 OR YOUNGER
INDIVIDUALS OR FAMILIES 65 OR OLDER
WAITING PERIODS
Waiting periods apply from the start date of your policy, from the effective option change date when you upgrade your policy, and from each person’s cover start date when they’re added after the policy’s start date. The Cover Letter you'll receive when your policy is activated will confirm the waiting periods that apply to each insured person.
3 MONTH GENERAL WAITING PERIOD
We don’t cover you during this period unless you claim for accidental events that occur after your cover start date.
EXCEPTION TO THE RULE
Out-Patient Specialist Consultation Cover offered on the ELITE option always receives a 3 Month General Waiting Period.
12 MONTH PRE-EXISTING CONDITION WAITING PERIOD
We don’t cover you during this period for investigations, medical procedures, surgeries or treatments related to any illness or medical condition that was diagnosed or that you received advice or treatment for within 12 months before your policy’s start date.
10 MONTH LIMITED PAYOUT BENEFIT
If you claim from our GAP COVER, CO-PAYMENT COVER, SUB-LIMIT COVER or ACCESS COVER in the first 10 months of cover for specific medical events, we'll cover only 20% of the approved claim amount subject to benefit limits where applicable.
If, however, your medical event is due to a medical condition that you received advice or treatment for within 12 months before the start date of your policy, your claim will be subject to a Pre-Existing Condition Waiting Period.
Accidental events don't form part of the 10 Month Limited Payout Benefit and aren't subject to any waiting periods.
PRE-EXISTING MEDICAL CONDITION DISCLOSURE
As the main applicant, you’re responsible to answer this section for yourself and on behalf of your dependants, where applicable, and agree that you have the necessary knowledge and consent to do so.
12 MONTH PRE-EXISTING CONDITION WAITING PERIOD
We don’t cover you during this period for investigations, medical procedures, surgeries or treatments related to any illness or medical condition that was diagnosed or that you received advice or treatment for within 12 months before your policy’s start date.
Medical events claimed within the first 12 months of cover, that we view as pre-existing which you didn't disclose at the time of applying for cover, may be investigated and rejected on the basis of non-disclosure.
Please provide details of any illness or medical condition that's relevant to you and/or any dependants, including the diagnosis date where applicable.
By submitting this application, you acknowledge and accept that your policy will be subject to waiting periods and/or a limited benefit in the first 10 months of cover for specific medical events, unless otherwise specified in your Cover Letter.
REPLACEMENT POLICY DISCLOSURE
As the Main Applicant completing this section or having it completed by your Broker, you understand that your current Gap Cover policy will be replaced with a Stratum Benefits policy and that certain aspects of the new policy will be different from the old policy.
DISCLOSURE
- Your monthly premium and/or special terms and conditions of cover may change because benefits and fee structures are different between policies.
- Our Policy Schedule explains the general exclusions, terms and conditions of cover in more detail.
- If there's a break in cover of 30 days or more between the end date of cover with the previous insurer and the cover start date with us, you'll receive full waiting periods.
GENERAL WAITING PERIOD
Depending on your age, a General Waiting Period might apply. We don't cover you during this period unless you claim for accidental events that occur after your cover start date.
Out-Patient Specialist Consultation Cover offered on the ELITE option always receives a 3 Month General Waiting Period.
PRE-EXISTING CONDITION WAITING PERIOD APPLICABLE TO LIKE-FOR-LIKE BENEFITS AND/OR ENHANCED BENEFITS
If your current Gap Cover policy has been active for less than 12 months and a Pre-Existing Condition Waiting Period applies, the balance of the waiting period will be carried over. If our Gap Cover policy offers enhanced benefits, these benefits will receive a 12 Month Pre-Existing Condition Waiting Period.
We don't cover you during this period for investigations, medical procedures, surgeries or treatments related to any illness or medical condition that was diagnosed or that you received advice or treatment for within 12 months before your policy's start date.
DISCLOSED PLANNED MEDICAL EVENTS
If you claim in the first 10 months of cover for a medical procedure, surgery, treatment or investigation that you informed us about when you applied to switch cover, we'll cover only 20% of the approved claim amount.
UNDISCLOSED MEDICAL EVENTS
If you claim in the first 12 months of cover for a medical procedure, surgery, treatment or an investigation, that we deem as pre-existing but that you didn’t tell us about when you applied to switch cover, may be investigated and rejected based on non-disclosure.
Click here to view our 2021 Gap Cover Transfer Process for Individuals to see which waiting periods could apply to you.
By submitting this application, you acknowledge and accept that your policy will be subject to waiting periods and/or a limited benefit in the first 10 months of cover for specific medical events, unless otherwise specified in your Cover Letter.
CORPORATE GAP COVER OPTIONS
Your monthly premium is subject to the quote accepted by your employer. Speak with your HR Representative or Broker about premium details.
Please select the Corporate Gap Cover option that your employer offers.
WAITING PERIODS
Waiting periods may apply from the start date of your policy and from each person's cover start date when they're added after the policy's start date.
The waiting periods that apply to you are determined by the demographic profile of the employer group and the quote accepted by your employer. Waiting periods will be confirmed in the Cover Letter that you'll receive when your policy is activated.
3 MONTH GENERAL WAITING PERIOD
We don't cover you during this period unless you claim for accidental events that occur after your cover start date.
EXCEPTION TO THE RULE
Out-Patient Specialist Consultation Cover offered on the CORPORATE ELITE PLUS option always receives a 3 Month General Waiting Period.
12 MONTH PRE-EXISTING CONDITION WAITING PERIOD
We don't cover you during this period for investigations, medical procedures, surgeries or treatments related to any illness or medical condition that was diagnosed or that you received advice or treatment for within 12 months before your policy's start date.
10 MONTH LIMITED PAYOUT BENEFIT
If you claim from our GAP COVER, CO-PAYMENT COVER, SUB-LIMIT COVER or ACCESS COVER in the first 10 months of cover for specific medical events, we'll cover between 20% and 100% of the approved claim amount subject to the quote accepted by your employer.
If, however, your medical event is due to a medical condition that you received advice or treatment for within 12 months before the start date of your policy, your claim will be subject to a Pre-Existing Condition Waiting Period if this waiting period applies to the employer group.
Accidental events don't form part of the 10 Month Limited Payout Benefit and aren't subject to any waiting periods.
By submitting this application form, you acknowledge and accept that your policy may be subject to waiting periods and/or the 10 Month Limited Payout Benefit if you claim in the first 10 months of cover for specific medical events.
Speak with your HR Representative, Broker or refer to our product brochure for more information about the listed medical events.
MEDICAL HISTORY DISCLOSURE
As the main applicant, you’re responsible to answer this section for yourself and on behalf of your dependants, where applicable, and agree that you have the necessary knowledge and consent to do so.
Whether or not a Pre-Existing Condition Waiting Period will apply to you or your dependants, please answer the below questions.
DETAILS
DETAILS
DETAILS
REPLACEMENT POLICY DISCLOSURE
As the Main Applicant completing, or having this section completed by your Broker, you understand that your current Gap Cover policy will be replaced with a Stratum Benefits policy and that certain aspects of the new policy will be different from the old policy.
DISCLOSURE
- Your monthly premium and/or special terms and conditions of cover may change because benefits and fee structures are different between policies.
- Our Policy Schedule explains the general exclusions, terms and conditions of cover in more details.
- If there's a break in cover of 30 days or more between the end date of cover with the previous insurer and the cover start date with us, you may receive full waiting periods.
TRANSFER WAITING PERIODS
Your policy will be subject to underwriting, regardless of whether you're switching cover between the same insurer or from a different insurer. Waiting periods applicable to our Corporate Product Range are subject to the demographic profile of the employer group.
The below waiting periods are standard waiting periods that may apply to you as an employee switching cover from another Gap Cover provider, subject to the quote accepted by your employer.
EXCEPTION TO THE RULE
Out-Patient Specialist Consultation Cover offered on the CORPORATE ELITE PLUS option always receives a 3 Month General Waiting Period.
PRE-EXISTING CONDITION WAITING PERIOD APPLICABLE TO LIKE-FOR-LIKE BENEFITS AND/OR ENHANCED BENEFITS
If your current Gap Cover policy has been active for less than 12 months and a Pre-Existing Condition Waiting Period applies, the balance of the applicable waiting period will be carried over. If our Gap Cover policy offers enhanced benefits, these benefits will receive a Pre-Existing Condition Waiting Period of up to 12 months.
We don't cover you during this period for investigations, medical procedures, surgeries or treatments related to any illness or medical condition that was diagnosed or that you received advice or treatment for within 12 months before your policy's start date.
By submitting this application, you acknowledge and accept that your policy may be subject to waiting periods.
If you haven’t selected a Health Insurance product, ignore and click Next.
HEALTH INSURANCE BENEFIT OPTIONS
Through a national network of providers who have contracted with Unity Health, our health insurance administrator, you have access to more than 3 000 GP’s, 2 700 optometrists and various pharmacies, pathologists and radiologists.
Need help in finding your nearest provider?
Visit www.unityhealth.co.za or contact us for assistance.
Our Essential Primary Plus product range offers healthcare solutions to individuals and families. Choose between our Day-to-Day Benefit Option, Emergency & Accident Benefit Option or our Day-to-Day, Emergency & Accident Benefit Option.
Our options complement your medical aid cover, or it can be taken as your primary health cover if you don’t have medical aid cover.
If you're 56 or older and apply for cover on the Day-to-Day Benefit Option or the Day-to-Day, Emergency and Accident Benefit Option, of if you're 61 or older applying for cover on the Emergency & Benefit Option, you'll pay a higher premium as indicated in the respective premium categories. If you can prove that you've been on medical aid or primary healthcare insurance cover for 15 or more consecutive years from the age of 35, the lower premium category will apply.
Children aged 20 years or younger pay child dependant premiums. Children aged 21 years or older pay adult dependant premiums if they are full-time students and proof of financial dependency is submitted every year.
We accept proof from the educational facility or stamped copies of your child’s bank account statements of the past 3 months.
If you select an incorrect policy premium that is not in line with the premium category on the Health Insurance option you’re applying for, your policy premium will be adjusted according to your age at entry.
DAY-TO-DAY BENEFIT OPTION
DAY-TO-DAY BENEFIT OPTION
EMERGENCY & ACCIDENT BENEFIT OPTION
EMERGENCY & ACCIDENT BENEFIT OPTION
DAY-TO-DAY, EMERGENCY& ACCIDENT BENEFIT OPTION
DAY-TO-DAY, EMERGENCY & ACCIDENT BENEFIT OPTION
Where would you like us to send your Health Insurance card to? Please give us the address if it's not the same as your physical address.
Allow +/- 21 working days for delivery depending on postal services.
WAITING PERIODS
Waiting periods apply from the start date of your policy, and from each person’s cover start date when they’re added after the policy’s start date. The Cover Letter you'll receive when your policy is activated will confirm the waiting periods that apply to each insured person.
2 MONTH GENERAL WAITING PERIOD
Cover does not apply to our Day-to-Day, Wellness Assessment and Preventative Care Benefits during the first 2 months of cover.
9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
12 MONTH CHRONIC MEDICATION WAITING PERIOD
12 MONTH EYE CARE WAITING PERIOD
EXCEPTION TO THE RULE
Waiting periods do not apply to our Emergency and Accident Benefits and Essential Assistance Programme (EAP).
By submitting this application form, you acknowledge and accept that your policy will be subject to waiting periods for specific medical events.
REPLACEMENT POLICY DISCLOSURE
DISCLOSURE
Waiting periods apply from the start date of the policy and from each insured person’s cover start date unless otherwise specified in your Cover Letter, which you will receive when your cover is activated.
Clients transferring cover must be informed of the following:
-
A change in monthly premium and/or special terms and conditions may apply as products are different in benefit and fee structure;
-
Our Policy Particulars provide more information about the general exclusions, terms and conditions of cover; and
- If there has been a break in cover of 30 days or more between the end date of cover with the previous medical aid and the cover start date of the new Health Insurance Benefit Option, full underwriting will apply.
STANDARD WAITING PERIODS
The below waiting periods are standard waiting periods that may or may not apply to a client’s policy when transferring.
2 MONTH GENERAL WAITING PERIOD
During the first 2 months of cover a general waiting period applies to our DAY-TO-DAY BENEFITS, WELLNESS ASSESSMENT BENEFIT and PREVENTATIVE CARE BENEFIT.
9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
12 MONTH CHRONIC MEDICATION WAITING PERIOD
12 MONTH EYE CARE WAITING PERIOD
Waiting periods may apply when transferring cover from a medical aid to a health insurance benefit option that offers Day-to-Day Benefits.
Click here to view our 2021 Health Insurance Transfer Process for Individuals to see which waiting periods may apply to you.
By submitting this application form, you acknowledge and accept that your policy will be subject to waiting periods for specific medical events.
NOMINATION OF BENEFICIARY
Please nominate 1 beneficiary to whom the benefit amount under our Accidental Death Benefit will be paid to in the event of your accidental death. If a beneficiary is not nominated the benefit amount will be paid to your estate.
In the event of your spouse's accidental death, the benefit amount will be paid to the principal insured person on the policy.
Please refer to your policy documentation for full terms and conditions.
As the main applicant, you understand that the beneficiary nominated will receive proceeds from the benefit payable under our Accidental Death Benefit, subject to the terms and conditions of your policy and/or limitations imposed by law at the time of your claimable event.
You also understand that:
- you may nominate a beneficiary of your choice;
- If your nominated beneficiary cannot be located or passes away prior to your claimable event, the benefit amount(s) payable to them will be paid to your estate;
- If at the time of payment your nominated beneficiary is a minor, the benefit amount(s) will be paid to the minor’s legal guardian or a trust for the benefit of the minor, or to any person we are authorised to pay under the relevant law;
- you may amend your nomination at any stage, however, nominations are not effective until confirmed in writing by the Insurer; and
- the benefit amount(s) payable to your nominated beneficiary will be based on the latest valid beneficiary nomination received as accepted by the Insurer.
CORPORATE ESSENTIAL
CORPORATEESSENTIALOPTIONS
Through a national network of providers who have contracted with Unity Health, our health insurance administrator, you have access to more than 3000 GP’s, 3000 optometrists and various pharmacies, pathologists and radiologists.
Need help in finding your nearest provider? Visit www.unityhealth.co.za or contact us for assistance.
Your monthly premium is subject to the quote accepted by your employer. Speak with your HR Representative or Broker about premium details.
Please select the Corporate Health Insurance option that your employer offers:
WAITING PERIODS
Waiting periods apply from the start date of your policy and from each insured person’s cover start date.
Waiting periods don’t apply to employer groups when 20 or more employees join on a compulsory basis.
When 20 or less employees join or when it’s voluntary for employees to join, the below waiting periods will apply.
The waiting periods that apply to you are determined by the demographic profile of the employer group and the quote accepted by your employer. Waiting periods will be confirmed in the Cover Letter that you’ll receive when your policy is activated.
1 MONTH GENERAL WAITING PERIOD
Cover doesn’t apply to the Day-to-Day, Employee Wellness Assessment or Preventative Care Benefits during the first month of cover.
9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
12 MONTH CHRONIC MEDICATION WAITING PERIOD
12 MONTH EYE CARE WAITING PERIOD
EXCEPTION TO THE RULE
Waiting periods don’t apply to the Emergency and Accident Benefit and Essential Assistance Programme (EAP).
By submitting this application form, you acknowledge and accept that your policy may be subject to waiting periods for specific medical events.
REPLACEMENT POLICY DISCLOSURE
Waiting periods apply from the start date of the policy and from each insured person’s cover start date unless otherwise specified in your Cover Letter, which you will receive when your cover is activated.
Clients transferring cover must be informed of the following:
DISCLOSURE
-
A change in monthly premium and/or special terms and conditions may apply as products are different in benefit and fee structure;
-
Our Policy Particulars provide more information about the general exclusions, terms and conditions of cover; and
- If there has been a break in cover of 30 days or more between the end date of cover with the previous medical aid and the cover start date of the new Health Insurance Benefit Option, full underwriting will apply.
STANDARD WAITING PERIODS
The below waiting periods are standard waiting periods that may or may not apply to a client’s policy when transferring.
2 MONTH GENERAL WAITING PERIOD
During the first 2 months of cover a general waiting period applies to our DAY-TO-DAY BENEFITS, WELLNESS ASSESSMENT BENEFIT and PREVENTATIVE CARE BENEFIT.
9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
12 MONTH CHRONIC MEDICATION WAITING PERIOD
12 MONTH EYE CARE WAITING PERIOD
Waiting periods may apply when transferring cover from a medical aid to a health insurance benefit option that offers Day-to-Day Benefits.
By submitting this application form, you acknowledge and accept that your policy will be subject to waiting periods for specific medical events.
NOMINATION OF BENEFICIARY
Please nominate 1 beneficiary to whom the benefit amount under our Accidental Death Benefit will be paid to in the event of your accidental death. If a beneficiary is not nominated the benefit amount will be paid to your estate.
In the event of your spouse's accidental death, the benefit amount will be paid to the principal insured person on the policy.
Please refer to your policy documentation for full terms and conditions.
As the main applicant, you understand that the beneficiary nominated will receive proceeds from the benefit payable under our Accidental Death Benefit, subject to the terms and conditions of your policy and/or limitations imposed by law at the time of your claimable event.
You also understand that:
- you may nominate a beneficiary of your choice;
- If your nominated beneficiary cannot be located or passes away prior to your claimable event, the benefit amount(s) payable to them will be paid to your estate;
- If at the time of payment your nominated beneficiary is a minor, the benefit amount(s) will be paid to the minor’s legal guardian or a trust for the benefit of the minor, or to
- any person we are authorised to pay under the relevant law;
- you may amend your nomination at any stage, however, nominations are not effective until confirmed in writing by the Insurer; and
- the benefit amount(s) payable to your nominated beneficiary will be based on the latest valid beneficiary nomination received as accepted by the Insurer.
YOUR PAYMENT PROFILE
By accepting this section and upon acceptance of your application, you:
- understand that cover will commence after the first premium is received.
- authorise Stratum Benefits to debit your account for the policy premium that's payable in advance, on the debit order date as selected.
- authorise Stratum Benefits to accept this debit order authority as a payment instruction issued by the account holder.
- accept that depending on the selected debit order date, a double debit may be incurred.
- agree that this debit order authority will remain in force until cancelled in writing by the principal insured person, or by Stratum Benefits if premiums are not received for two consecutive months.
- understand that this debit order authority may only be assigned to a third party if this contract is also assigned to a third party.
- understand that if your payment date falls on a Sunday, or recognised South African public holiday, the debit order date will default to the next working day.
- accept that if the premium from a previous debit order deduction is returned, a R 25 admin fee will be added to the next premium deduction.
- accept that your premium may be adjusted during an annual renewal or due to benefit restructuring necessitated by legislation with one month’s written notice, and subject to your right of cancellation of cover, the debit order authority will extend to the adjusted premium.
- understand that your debit order deductions will be processed through a computerised system provided by the South African Banks. Details of each debit order deduction will be displayed on your bank statement with the reference prefix "STRATUM", followed by an 8 digit number ending with "NETCASH".
- accept that given the debit order authority granted by you, it is your responsibility to ensure that premiums are collected in order to remain covered.
- accept that you'll not be entitled to any refund of amounts which have been deducted while this debit order authority is in force, if such amounts were legally due.
- understand that the product premium is inclusive of VAT.
YOUR PAYMENT PROFILE
You’ll receive an invoice for the premiums due from your cover start date up until December 2021. A new invoice will be sent to you for the new benefit year once your chosen Gap Cover option’s premium increase is confirmed.
Banking details
By accepting this section and upon acceptance of your application, you:
- understand that cover will commence after the first premium is received.
- authorise Stratum Benefits to debit your account for the policy premium that's payable in advance, on the debit order date as selected.
- authorise Stratum Benefits to accept this debit order authority as a payment instruction issued by the account holder.
- accept that depending on the selected debit order date, a double debit may be incurred.
- agree that this debit order authority will remain in force until cancelled in writing by the principal insured person, or by Stratum Benefits if premiums are not received for two consecutive months.
- understand that this debit order authority may only be assigned to a third party if this contract is also assigned to a third party.
- understand that if your payment date falls on a Sunday, or recognised South African public holiday, the debit order date will default to the next working day.
- accept that if the premium from a previous debit order deduction is returned, a R 25 admin fee will be added to the next premium deduction.
- accept that your premium may be adjusted during an annual renewal or due to benefit restructuring necessitated by legislation with one month’s written notice, and subject to your right of cancellation of cover, the debit order authority will extend to the adjusted premium.
- understand that your debit order deductions will be processed through a computerised system provided by the South African Banks. Details of each debit order deduction will be displayed on your bank statement with the reference prefix "STRATUM", followed by an 8 digit number ending with "NETCASH".
- accept that given the debit order authority granted by you, it is your responsibility to ensure that premiums are collected in order to remain covered.
- accept that you'll not be entitled to any refund of amounts which have been deducted while this debit order authority is in force, if such amounts were legally due.
- understand that the product premium is inclusive of VAT.
PROSPECTIVE CLIENT CONSENT
Declaration
As the main applicant applying for insurance cover, I understand and acknowledge that the Corporate Gap Cover and/or Corporate Health Insurance Option I'm applying for is not a medical aid, doesn't provide similar cover as that of a medical aid and can't be substituted for medical aid membership.
I hereby declare and accept that:
- I'm applying for insurance cover subject to the waiting periods, benefit and general exclusions, terms and conditions of the policy contract and confirm that these have been communicated and explained to me prior to my cover start date.
- all the information provided is true and correct and that no information has been withheld that may be material to, or likely to affect the assessment or acceptance of my risk.
- in the event of any material non-disclosure or misrepresentation, my policy may be rendered null and void. I accept that I will forfeit any and all premiums and that Stratum Benefits may decline to indemnify or compensate me and/or my dependant(s) where applicable, for any claims under any item or section of cover.
- should this application form be incomplete, it may not be processed by Stratum Benefits.
- I understand that this insurance cover is not a medical aid membership nor does it provide benefits similar to that of a medical aid.
- my, and my dependant’s eligibility for cover is dependent on us remaining active members of a registered medical aid and I undertake to advise Stratum Benefits if I terminate my, and/or my dependant’s medical aid membership at any time.
- in terms of the Financial Advisory and Intermediary Services Act, 2002 (FAIS), my broker must be mandated by a licensed Financial Services Provider (FSP) as a representative with the necessary (FAIS) sub-categories to act on my behalf and that it is my responsibility to determine whether my broker has the necessary authorisation.
- I've appointed the above-mentioned broker and authorise payment of their monthly commission.
- Stratum Benefits is irrevocably authorised to process and store my and/or my dependant’s personal information required for the purpose of administrating cover under this policy, and I undertake to notify Stratum Benefits of any change in my personal details within a reasonable time period.
PROSPECTIVE CLIENT CONSENT
PROSPECTIVE CLIENT CONSENT
Declaration
As the main applicant applying for insurance cover, I understand and acknowledge that the Gap Cover/Health Insurance Option I'm applying for is not a medical aid, doesn't provide similar cover as that of a medical aid and can't be substituted for medical aid membership.
I hereby declare and accept that:
- I'm applying for insurance cover subject to the waiting periods, benefit and general exclusions, terms and conditions of the policy contract and confirm that these have been communicated and explained to me prior to my cover start date.
- all the information provided is true and correct and that no information has been withheld that may be material to, or likely to affect the assessment or acceptance of my risk.
- in the event of any material non-disclosure or misrepresentation, my policy may be rendered null and void. I accept that I will forfeit any and all premiums and that Stratum Benefits may decline to indemnify or compensate me and/or my dependant(s) where applicable, for any claims under any item or section of cover.
- should this application form be incomplete, it may not be processed by Stratum Benefits.
- I understand that this insurance cover is not a medical aid membership nor does it provide benefits similar to that of a medical aid.
- my, and my dependant’s eligibility for cover is dependent on us remaining active members of a registered medical aid and I undertake to advise Stratum Benefits if I terminate my, and/or my dependant’s medical aid membership at any time.
- in terms of the Financial Advisory and Intermediary Services Act, 2002 (FAIS), my broker must be mandated by a licensed Financial Services Provider (FSP) as a representative with the necessary (FAIS) sub-categories to act on my behalf and that it is my responsibility to determine whether my broker has the necessary authorisation.
- I've appointed the above-mentioned broker and authorise payment of their monthly commission.
- Stratum Benefits is irrevocably authorised to process and store my and/or my dependant’s personal information required for the purpose of administrating cover under this policy, and I undertake to notify Stratum Benefits of any change in my personal details within a reasonable time period.
E&OE