Gap Cover Membership Application Form (Compulsory) Gap Cover Membership Application Form (Compulsory) 1Your Personal Details2Employer Details3Your Medical Scheme & Dependants4WARRANTY & CONSENT This field is hidden when viewing the formpart_typevltcmpUsed 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.Please indicate the capacity in which you are completing this application form:I am completing this application as :(Required) Employee Employer Healthcare Intermediary Employee NumberTitle(Required)Please select from the list belowAdvDrMissMrMrsMsProfName and Surname(Required) First Last 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)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required)FemaleMaleAddress(Required) Street Address Address Line 2 City Province Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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. Consent(Required) I agree to above declaration as it relates to my personal information 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 premiums on my behalf. Please enter your employer’s name(Required)If your company is part of a group of companies, please enter group name or descriptionWhat is your employee number?(Required)When did your employment start?(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Commencement Date of Your Policy(Required)1 March 20241 April 2024Please note that your policy can only commence on the 1st day of a monthThis field is hidden when viewing the formCommencement Date of Your PolicyPlease note that your policy can only commence on the 1st day of a month Medical Scheme(Required)Please select your Medical SchemeAlliance-MidmedPolmedRemedi HealthTBCThebemedWitbank Coalfields Medical AidDiscoveryMomentumCAMAFProfmed (PPS)FedhealthMedihelpBonitasBankMedBestMedCape Medical PlanCompCareGEMSGenesisHealth SquaredHosmedKeyHealthLA-HealthMakotiMedshieldMotohealth CareOtherSizweSuremedTransmedMembership NumberCommencement date of medical scheme membership(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Benefit Option(Required)Please select your planAlliance-MidmedAquariumMarineAlltbctbctbcClassic ComprehensiveClassic Delta SaverClassic PriorityClassic SaverClassic SmartCoastal CoreCoastal SaverEssential CoreEssential Delta CoreEssential Delta SaverEssential SmartKeyCare PlusEssential PriorityExecutiveClassic Delta ComprehensiveEssential ComprehensiveEssential Delta ComprehensiveClassic CoreClassic Delta CoreEssential SaverKeyCare StartKeyCare CoreClassic Smart ComprehensivetbcEssential Dynamic SmartSummitIncentiveExtenderCustomIngweEvolveAllianceDouble PlusEssential PlusFirst ChoiceNetwork ChoiceVitalProActiveProActive PlusProPinnacleProSecure PlusProSecuremaxima Plusmaxima ExecmyFEDflexiFED 1flexiFED 2flexiFED 3flexiFED 4FlexiFED SavvyPrime 1Prime 2Prime 3NecesseUnifyPlusEliteMedElectMedSaverBonEssentialBoncapBonClassicStandardBonSaveBonCompletePrimaryPrimary SelectStandard SelectBonComprehensiveBonEssential SelectBonFitHospital StandardBonStartBonstart PlusEssential PlanBasic PlanCore Saver PlanTraditional PlanComprehensive PlanPlus PlanPace 3Beat 2Pace 1Beat 1Beat 3Beat 4Pace 2Pace 4Pulse 1Pulse 2Rhythm1Rhythm2HealthPact PremiumHealthPact SilverHealthPact SelectPinnacleDynamixSymmetryMumedUnisaveSelfsureMedXTanzanite OneBerylRubyEmeraldOnyxEmerald Value (EVO)PrivatePrivate ChoicePrivate PlusPrivate ComprehensiveCobaltUltimateMillenniumOptimumAdvanceFlex PlusFlexAspireRiseFoundationEssentialPlusValue CoreAccessValueEquilibriumEssenceGoldSilverOriginPlatinumLA ActiveLA CoreLA KeyPlusLA FocusLA ComprehensivePrimaryComprehensiveMediValueMediSaverMedicoreMediBonusPremium PlusMediPlusMediPhilaOptimumClassicEssentialHospicareCustomOtherTitaniumPlatinumGoldSilverCopperAccessNavigatorChallengerShuttleExplorerState Plus NetworkGuardianPrivate NetworkState Plus Free ChoiceSelect Plan Disclosure of Relevant Information(Required)I warrant and declare that all the information provided in this application form, whether completed by myself or on my behalf, is provided accurately, honestly and as complete as possible. I know and understand that any non-disclosure or misrepresentation or breach of any of the warranties I have given herein may result in my claim being rejected or my policy being cancelled or voided. As the main applicant I also understand that I am providing the details herein and completing the medical questions for myself and for my dependants and that I have the necessary knowledge and authority to share such information and answer all the medical questions accurately, honestly and completely. I have read and understood the above warranty and agree to it.Consent to Access Medical Records and Personal Information(Required)I hereby give Cinagi and its underwriter, Infiniti Insurance Ltd, consent to obtain the medical records, medical claims and personal information for myself and my dependants for the purposes of underwriting the risk under this policy. I agree that such consent extends to obtaining medical records or personal information from my medical scheme and our medical service providers, including their sub-contractors who process or transfer the relevant medical records, medical claims and personal 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 I am duly authorised to provide such consent for myself and my dependants. I have read and understood the above consent and agree to it.We’re almost done – thank you for your patience. As part of the process of completing this application for insurance cover I hereby warrant, declare, confirm and acknowledge that: I have read and understood the contents of this application form and agree to be bound by the terms and conditions of the application form, the policy document and policy schedule, which together, form the policy contract. All the information provided in this application is true, honest and accurate and I have disclosed all material information to Cinagi. I have not withheld any information which may be material to the assessment of risk under this policy. 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, and such medical advice, treatment or diagnosis is either material to the assessment of risk under this policy or would have caused you to change your answer/s to the medical questions in this application, I will immediately inform Cinagi of such medical treatment prior to the inception of this policy. If I breach any of the warranties given, Cinagi may reject any claim under this policy, cancel this policy or void this policy from inception and I will forfeit any premiums paid. I, as the applicant, have the necessary authority and knowledge to complete the medical questions and provide the warranties provided in the medical questionnaire section above on behalf of myself and all of the dependants covered on this policy (if applicable). I have read the brochure outlining the cover and fully understand the cover I am purchasing. I acknowledge that this policy is not a medical scheme and that the cover is not the same as that of a medical scheme. Eligibility for cover under this policy requires that my dependents and I are active and paid-up beneficiaries of either my own or my spouse’s medical scheme. Should I add or remove any dependent from medical scheme cover or should the benefit option of the medical scheme under which we are currently covered change, that I will immediately notify Cinagi of such change. My children or stepchildren (if applicable) covered under this policy will be charged child rates until they are 24 years old, after which they will be charged adult rates. Should I wish to cancel this policy, I have 21 days within which to do so from the date of application and any premiums deducted or paid to Cinagi will be repaid to me and no cover will be activated. After 21 days, I can cancel this policy on 30 days’ notice, subject to the terms and conditions of the policy and any conditions of participation that may be imposed upon me by my employer (if applicable). I hereby authorise Cinagi to process and store my own and my dependents’ personal information for the purpose of administering this policy. I hereby give my financial adviser and the brokerage that employs them authority to deal with and complete this policy application form on my behalf as well as authority to deal with my policy once it is activated. It is my responsibility to ensure that the monthly premiums are paid on the due date, regardless of whether these may be undertaken on my behalf by my employer or directly against my bank account via debit order. I acknowledge that if premiums are in arrears by 15 days or more, my policy may be suspended and if premiums are in arrears by more than 30 days or more my policy may be cancelled. CONSENT TO ACCESS MEDICAL RECORDS AND PERSONAL INFORMATION 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. Consent(Required) I agreePhoneThis field is for validation purposes and should be left unchanged. Δ