cinagi-app-corp

Gap Cover Membership Application Form (Compulsory with Bank Details)

1Your Personal Details

2Medical Scheme

3Banking

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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 compulsary employer’s group scheme.

Name and Surname(Required)

Email(Required)

Enter Email Confirm Email

Cellphone number(Required)

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 premiums 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.

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Days Employed

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

Cover will in my private capacity with monthly prmeiums being paid via debit order.(Required)

Cover will in my private capacity with monthly premiums being paid via debit order.

Medical Scheme(Required)

Membership Number

Commencement date of medical scheme membership(Required)

Benefit Option(Required)