Step 1 of 8 12% Employer DetailsEmployer Name*Company Registration Number*Tax Reference Number*Company VAT registration numberCountry of Incorporation*Company Physical Address* Street Address Address Line 2 City Province Postal Code Company Postal Address Street Address Address Line 2 Postal Code Company Website Company Contact DetailsContact Person* Name Surname Designation*Contact Number (Landline)*Contact Number (Cell)*Email* Company Product SelectionProducts* Gap CORE Gap MAX Gap SELECT Emergency Accident Premium Collection DetailsNumber of Pay points*Please enter a number from 1 to 7.Contact Person and Billing Details for Pay Point 1Pay Point Name*Contact Person* Name Surname Contact Number (Landline)*Contact Number (Cell)*Billing Email* Enter Email Confirm Email Monthly billing statements, reconciliations and premium notices will be sent to the above email address.Premium Collection Method* Monthly electronic transfer to insurer Monthly individual debit order Contact Person and Billing Details for Pay Point 2Pay Point Name*Contact Person* Name Surname Contact Number (Landline)*Contact Number (Cell)*Billing Email* Enter Email Confirm Email Monthly billing statements, reconciliations and premium notices will be sent to the above email address.Premium Collection Method* Monthly electronic transfer to insurer Monthly individual debit order Contact Person and Billing Details for Pay Point 3Pay Point Name*Contact Person* Name Surname Contact Number (Landline)*Contact Number (Cell)*Billing Email* Enter Email Confirm Email Monthly billing statements, reconciliations and premium notices will be sent to the above email address.Premium Collection Method* Monthly electronic transfer to insurer Monthly individual debit order Contact Person and Billing Details for Pay Point 4Pay Point Name*Contact Person* Name Surname Contact Number (Landline)*Contact Number (Cell)*Billing Email* Enter Email Confirm Email Monthly billing statements, reconciliations and premium notices will be sent to the above email address.Premium Collection Method* Monthly electronic transfer to insurer Monthly individual debit order Contact Person and Billing Details for Pay Point 5Pay Point Name*Contact Person* Name Surname Contact Number (Landline)*Contact Number (Cell)*Billing Email* Enter Email Confirm Email Monthly billing statements, reconciliations and premium notices will be sent to the above email address.Premium Collection Method* Monthly electronic transfer to insurer Monthly individual debit order Contact Person and Billing Details for Pay Point 6Pay Point Name*Contact Person* Name Surname Contact Number (Landline)*Contact Number (Cell)*Billing Email* Enter Email Confirm Email Monthly billing statements, reconciliations and premium notices will be sent to the above email address.Premium Collection Method* Monthly electronic transfer to insurer Monthly individual debit order Contact Person and Billing Details for Pay Point 7Pay Point Name*Contact Person* Name Surname Contact Number (Landline)*Contact Number (Cell)*Billing Email* Enter Email Confirm Email Monthly billing statements, reconciliations and premium notices will be sent to the above email address.Premium Collection Method* Monthly electronic transfer to insurer Payment & Participation DetailsGroup Scheme Inception Date*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Cover participation* Cover is compulsory for all employees Cover will be compulsory from now on, but current employees have the option to opt out before the agreed cutoff. Employees can voluntarily select to take out cover Notes : The billing details of all new applications will be sent to the billing e-mail address as and when the applications are completed. Intermediary DetailsBrokerage*Name of Consultant*Consultant Email* Consultant Contact Number* Supporting DocumentationCIPC DOCUMENTS* Drop files here or Select files Max. file size: 2 GB. PROOF OF ADDRESS NOT OLDER THAN 3 MONTHS* Drop files here or Select files Max. file size: 2 GB. Employer WarrantyOn behalf of the Employer* Name Surname Employer Acknowledgement that by completing and submitting this form I am authorised by the employer to enter into this agreement and establish a group scheme for the employer. that the employer will facilitate the deduction of premiums from employees, where applicable,and pay these across to Cinagi by the 1st working day of each month. that the member participation and payment terms and conditions outlined above are accurate. that the employer will provide Cinagi with updated staff details each month (where applicable). that the appointed intermediary may assist Cinagi with updating membership & billing information if required. Acknowledgement* I acknowledge and accept the terms above. Sharing of Personal Information Declaration By providing the information in this form or any annexures hereto and having applied for cover on behalf of the employees of your organisation you agree that Cinagi (Pty) Ltd and its underwriter, Infiniti Insurance Ltd may : use this information to provide the employees of your organisation 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 the employees of your organisation with the aforementioned services. have the right to communicate with the employees of your organisation electronically about any changes or general information relating administrative processes or changes to policy benefits and premiums. only transfer personal information outside South Africa if the provided email addresses are hosted outside South Africa or to administer certain services, for example, cloud services and/or the Medical Second Opinion service. You further agree that: by submitting personal infromation relating to employees and/or their dependents’ of your organisation, you are duly 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 specific consent has been obtained from each employee as defined in the Act, or in the absence of specific consent that the purpose for processing personal information as outlined in the Cinagi Privacy Statement is compatible with or in accordance with the purpose for which the personal information of each employee was collected in the first place. You also acknowledge that that you have read and agreed to the Cinagi Privacy Statement and the contents thereof. Consent* I agree to above declaration as it relates to the sharing of personal informationToday's DateDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Δ