Gap Cover Application Form

Gap Cover Membership Application Form

1Your Details

2Application Status

3Your Medical Scheme

4Your Dependants

5Bank Details & Previous Cover

6Questionnaire

7Declaration

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part_type

Used in back end for existing employers. When compulsory many of the fields are already known or not required. known fields will be dynamically populated.

This application form can be used to join your employer’s group scheme or to join in your private capacity.

Please note that you will need the following in order to complete this application form:

Your cell phone to receive an OTP via sms
If applicable, your spouse’s ID number (or passport number)
If applicable, the birthdates of your children
The benefit option of your medical scheme that you are covered on
Name of the advisor who advised you on this policy application

Title(Required)

Name and Surname(Required)

Email(Required)

Enter Email Confirm Email

Cellphone number(Required)

Alternative telephone number

Form of identification(Required)

South African Identity Number

Passport Number

ID No(Required)

Passport No.(Required)

Date of Birth(Required)

Gender(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code Country

Sharing of Personal Information Declaration

By providing the information in this form and having applied for cover you agree that Cinagi (Pty) Ltd and its underwriter, Infiniti Insurance Ltd may :

use this information to provide you with administrative and insurance services.
disclose this information to persons and entities that it is necessary to disclose this information to in order to provide you with the aforementioned services.
communicate with you electronically about any changes or general information relating to administrative processes or changes to your policy benefits and monthly costs or new/upgraded services or products that are available.
only transfer your personal information outside South Africa if you have provided an email address that is hosted outside South Africa or to administer certain services, for example, cloud services and/or the Medical Second Opinion service.
process the personal information of your spouse and/or other dependents, if you included them on your application, for the activation of the policy and to pursue their legitimate interests.

You further agree that:

by submitting your dependents’ personal information, you hereby confirm that you are authorised to share such information with us. We will furthermore process their information for the purposes and in the manner as set out in our Privacy Statement
if you are giving consent for a person under the age of 18 years (a minor), you confirm that you are a competent person and that you have authority to give their consent on their behalf.

You also acknowledge that that you have read and agreed to the Cinagi Privacy Statement and the contents thereof.

Please select the correct status below for your application:(Required)

I am joining my employer’s group scheme with Cinagi and my employer will deduct and/or pay the monthly costs on my behalf.

I am joining my employer’s group scheme with Cinagi and my monthly cost will be deducted via debit order from my personal bank account.

I am joining Cinagi in my private capacity and my monthly cost will be deducted via debit order from my personal bank account.

I am currently a Cinagi policyholder via my employer’s group scheme and wish to convert to private membership because I’m resigning/retiring. Monthly costs will be deducted via debit order from my personal bank account.

Please enter your employer’s name(Required)

If your company is part of a group of companies, please enter group name or description

What is your employee number?(Required)

When did your employment start?(Required)

Name of the advisor on this policy application

Advisor's email address

Advisor's cellphone number

Name of Brokerage

Please enter your existing Cinagi policy number(Required)

If you do not know your current policy number please get in touch with us. https://www.cinagi.co.za/contact/

Commencement Date of Your Policy(Required)

Please note that your policy can only commence on the 1st day of a month

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Commencement Date of Your Policy

Please note that your policy can only commence on the 1st day of a month

I hereby confirm my application for the following policy(Required)

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I hereby confirm my application for the following policy(Required)

Enter the OTP sent to your cellphone(Required)

To verify your cell number, we have sent you a 6-digit One-Time-Pin via SMS – please enter the OTP above. If you have not received it, please click on the back button below and navigate back to this page to trigger a resend.

Please note that you can only add your spouse and/or children to your policy, and you must all be registered on the same medical scheme membership.

You or your spouse (if relevant) can be the applicant for this policy. As long as all the insured persons on this policy are registered on the same medical scheme membership.

Description of Dependant Types :
Spouse – this includes a common-law spouse or life partner
Children - includes stepchildren
Notes on Child Dependants

A maximum of two children will be charged on your policy until they are 27 years old.
The monthly cost for adults will apply to all children from age 27 onwards on your policy and who are covered by your medical scheme.
There is no maximum age for children to stay on your policy, as long as they are registered on the same medical scheme membership as you are.
Once they resign from your medical scheme membership, then they would need to apply for their own Cinagi policy.

Other Dependants – dependant types covered on your medical scheme that are not your spouse and/or children (eg parents) will need to apply for their own Cinagi policy

Medical Scheme(Required)

Membership Number

Commencement date of medical scheme membership(Required)

Benefit Option(Required)

The correct monthly costs and policy cover are determined by your benefit option – it is very important that you select the correct benefit option above.

Please indicate what dependants are to be added to this policy

Spouse

Children

How many children are to be added to cover?(Required)

Confirmation(Required)

I confirm that these dependants and myself are all registered on the medical scheme membership provided above.

Details of Spouse

Title(Required)

Name(Required)

First Name Surname

Form of identification(Required)

South African Identification Number

Passport Number

ID No(Required)

Passport No(Required)

Date of Birth(Required)

Gender(Required)

Would you like us to copy your spouse on all Cinagi e-mail and sms communications sent to you?(Required)

Yes

Your spouse's cellphone number(Required)

Your spouse's email address(Required)

Details of your Children

Child's Name(Required)

First Name Surname

Child's Date of Birth(Required)

Child's Gender(Required)

2nd Child's Name(Required)

First Name Surname

2nd Child's Date of Birth(Required)

2nd Child's Gender(Required)

3rd Child's Name(Required)

First Name Surname

3rd Child's Date of Birth(Required)

3rd Child's Gender(Required)

4th Child's Name(Required)

First Name Surname

4th Child's Date of Birth(Required)

4th Child's Gender(Required)

5th Child's Name(Required)

First Name Surname

5th Child's Date of Birth(Required)

5th Child's Gender(Required)

6th Child's Name(Required)

First Name Surname

6th Child's Date of Birth(Required)

6th Child's Gender(Required)

Bank Details

Please confirm your banking details below for the monthly debit order deduction – deductions are made in advance on the 1st day of each month:

Bank Name(Required)

Account Holder Name(Required)

Account Type(Required)

Account Number(Required)

Branch Code(Required)

Your monthly costs will be

Previous Gap Cover

Please note that the application of waiting periods on your policy will depend on you providing us with sufficient evidence of your previous cover.

Do you currently have gap cover with another provider?(Required)

Yes

Name of the other gap cover provider?(Required)

When did this policy commence?(Required)

Policy Number(Required)

When does or did the cover on this policy end?(Required)

Please read the ‘Disclosure of Relevant Information’ and ‘Consent to Access Medical Records and Personal Information’ sections below carefully and ensure that you understand them and your obligations in supplying information that is true, honest and complete.

As the main applicant, you are completing the questions below on behalf of your dependents and you confirm that you have the necessary knowledge and authority to fully do so. It remains your responsibility to answer all of these questions accurately and honestly.

Please answer all the questions below :

Question 1: In the past 12 months, have you or any dependant consulted with or received advice, treatment or diagnosis from any doctor or medical service provider, and/or undergone any form of x-ray or CT/MRI/PET scan?(Required)

Yes

Question 2: Are you aware of any reason - including pregnancy/childbirth - that you or any dependant may be admitted to a hospital or a day clinic within the next 12 months?(Required)

Yes

Question 3: Do you or any dependant currently: take any ongoing medication, and/or receive any other ongoing treatment for any medical condition?(Required)

Yes

Details for Question 1

Please provide the details below in relation to your answer to Question 1:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Date of Treatment / Consultation(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

Please provide any further details regarding the treatment, advice or diagnosis received(Required)

Does Question 1 also apply to another applicant?(Required)

2nd Set of Details for Question 1

Please provide the details below in relation to your answer to Question 1 for the second person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Date of Treatment / Consultation(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

Please provide any further details regarding the treatment, advice or diagnosis received(Required)

Does Question 1 also apply to another applicant?(Required)

3rd Set of Details for Question 1

Please provide the details below in relation to your answer to Question 1 for the third person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Date of Treatment / Consultation(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

Please provide any further details regarding the treatment, advice or diagnosis received(Required)

Does Question 1 also apply to another applicant?(Required)

4th Set of Details for Question 1

Please provide the details below in relation to your answer to Question 1 for the fourth person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Date of Treatment / Consultation(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

Please provide any further details regarding the treatment, advice or diagnosis received(Required)

Does Question 1 also apply to another applicant?(Required)

Our online application form can only facilitate a maximum of 4 applicants’ answers to a medical question. Please continue to complete this application and once we have received it, we will contact you in order to obtain the additional medical answers that you wish to provide for the 5th applicant on your policy. Please note that your policy application will not be activated until we have received this additional information.

Details for Question 2

Please provide the details below in relation to your answer to Question 2:

Which applicant does this relate to?(Required)

Please describe the diagnosis and/or condition(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

When is the admission expected?(Required)

What date is the admission booked for?(Required)

Please provide any further details regarding the expected treatment(Required)

Does Question 2 also apply to another applicant?(Required)

2nd Set of Details for Question 2

Please provide the details below in relation to your answer to Question 2 for the second person:

Which applicant does this relate to?(Required)

Please describe the diagnosis and/or condition(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

When is the admission expected?(Required)

What date is the admission booked for?(Required)

Please provide any further details regarding the expected treatment(Required)

Does Question 2 also apply to another applicant?(Required)

3rd Set of Details for Question 2

Please provide the details below in relation to your answer to Question 2 for the third person:

Which applicant does this relate to?(Required)

Please describe the diagnosis and/or condition(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

When is the admission expected?(Required)

What date is the admission booked for?(Required)

Please provide any further details regarding the expected treatment(Required)

Does Question 2 also apply to another applicant?(Required)

4th Set of Details for Question 2

Please provide the details below in relation to your answer to Question 2 for the fourth person:

Which applicant does this relate to?(Required)

Please describe the diagnosis and/or condition(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

When is the admission expected?(Required)

What date is the admission booked for?(Required)

Please provide any further details regarding the expected treatment(Required)

Does Question 2 also apply to another applicant?(Required)

Details for Question 3

Please provide the details below in relation to your answer to Question 3:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Date of your last consultation(Required)

Please provide further details regarding the above treatment(Required)

Does Question 3 also apply to another applicant?(Required)

2nd Set of Details for Question 3

Please provide the details below in relation to your answer to Question 3 for the second person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Date of your last consultation(Required)

Please provide further details regarding the above treatment(Required)

Does Question 3 also apply to another applicant?(Required)

3rd Set of Details for Question 3

Please provide the details below in relation to your answer to Question 3 for the third person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Date of your last consultation(Required)

Please provide further details regarding the above treatment(Required)

Does Question 3 also apply to another applicant?(Required)

4th Set of Details for Question 3

Please provide the details below in relation to your answer to Question 3 for the fourth person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Date of your last consultation(Required)

Please provide further details regarding the above treatment(Required)

Does Question 3 also apply to another applicant?(Required)

We’re almost done – thank you for your patience.

By completing and submitting this application, I hereby warrant, declare, confirm, and acknowledge all of the following:

1. Any reference herein to “Cinagi” includes Cinagi (Pty) Ltd and any of Cinagi’s subsidiaries, holding companies, sister companies, affiliates, partners, underwriters, or service providers.
2. I have read and understood the contents of this application for insurance cover and agree to be bound by the terms and conditions of the application form, the insurance policy document, and the insurance policy schedule, which together form the insurance policy contract between myself and the underwriter.
3. All the information provided in this application is true, honest, and accurate, and I have disclosed all material information.
4. I have not withheld any information which may be material to the assessment of risk under this policy.
5. I declare that, in the event that any medical advice, treatment, or diagnosis that I or my dependants receive between the date of this application for cover and the date that the cover will incept is material to the assessment of risk under this policy, or would have caused me to change my answers to the medical questions in this application, I will immediately inform Cinagi of such medical advice, treatment, or diagnosis prior to the inception of this policy.
6. If I breach any of the warranties given, I acknowledge that Cinagi may reject any claim under this policy, cancel this policy, or void this policy from inception, and that I will forfeit any monthly costs paid for such cover.
7. I, as the applicant, have the necessary authority and knowledge to complete the medical questionnaire in this application truthfully, honestly, and accurately on behalf of myself and all dependants included on this policy and thus provide the warranties in this declaration on behalf of myself and all such dependants (where applicable).
8. I have read the brochure outlining the insurance cover and fully understand that I am purchasing the insurance cover, as well as any supplementary value-added services that may be included with the insurance cover.
9. I acknowledge that this policy is not a medical scheme and that the insurance cover is not the same as that of a medical scheme.
10. Eligibility for insurance cover under this policy requires that my dependants and I are active and paid-up beneficiaries of either my own or my spouse’s medical scheme.
11. Should I add or remove any dependant from medical scheme cover, or should the benefit option of the medical scheme under which we are currently covered change, I agree to immediately notify Cinagi of such change.
12. My children or stepchildren (if applicable) covered under this policy will be charged child rates until they reach 27 years of age, after which adult rates will apply.
13. Should I wish to cancel this policy, I have 21 days from the date of application for cover within which to do so. Any monthly payments made to Cinagi within this period will be repaid to me, and no cover will be activated.
14. After 21 days from the date of application for cover, I may cancel this policy on 31 days’ written notice, subject to the terms and conditions of the policy and any conditions of participation imposed by my employer (where applicable).
15. I hereby authorise Cinagi to process and store my own and my dependants’ personal information for the purpose of administering this policy and/or providing any supplementary value-added services included with the insurance cover.
16. I hereby authorise my financial adviser and/or intermediary and/or the brokerage that employs them to complete this policy application form on my behalf and to deal with my policy and any related administration once it is activated.
17. It is my responsibility to ensure that the monthly costs for the insurance cover, and any supplementary value-added services included with the insurance cover, are paid on the due date, regardless of whether payment is made by my employer or directly via debit order. I acknowledge that if any monthly amounts are in arrears by 15 days or more, my policy and cover may be suspended, and if arrears exceed 31 days, my policy and any related services may be cancelled.