This application form can be used to join your employer’s group scheme or to join in your private capacity.
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 :
You further agree that:
You also acknowledge that that you have read and agreed to the Cinagi Privacy Statement and the contents thereof.
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.
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.
I hereby give Cinagi and its underwriter, Infiniti Insurance Ltd, consent to obtain the medical records, medical claims or personal information for myself and my dependants for the purposes of underwriting the risk under this policy and/or to assess any claims against the policy. I agree that such consent extends to Cinagi and its underwriter, Infiniti Insurance Ltd, obtaining medical records, medical claims or personal information from my medical scheme and/or our medical service providers, including their sub-contractors who process or transfer the relevant medical records, medical claims and personal information between your medical scheme and your medical service providers. I agree that such consent also extends to Cinagi and its underwriter, Infiniti Insurance Ltd, obtaining medical records, medical claims or personal information data from medical data bureaus or credit bureaus who respectively act as aggregators of medical and credit information. I agree that this consent applies to the medical records, medical claims and personal information of myself and my dependants, and I declare that as the applicant for the cover under this policy I am duly authorised to provide such consent for myself and my dependants.