Medical Questionnaire

Sharing of Personal Information Declaration

By providing the information in this form 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.
have the right to communicate with you electronically about any changes or general information relating administrative processes or changes to the Cinagi policy benefits and premiums.
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.

You further agree that:

if submitting your dependents’ relevant personal information, you hereby confirm that 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
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 not withheld any information which may be material to the assessment of risk under this policy.

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, that of my policy dependents and medical information .

Name(Required)

First name Surname

Email(Required)

Enter Email Confirm Email

Cell Phone(Required)

ID or Passport number (Policyholder)(Required)

Cinagi Policy Number(Required)

Question 1: In the past 12 months, have you or any dependant consulted/received advice from any medical specialist, and/or undergone any form of X-ray / 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

Which dependent on your policy does your answer to question 1 relate to ?(Required)

Name and surname

ID or Passport number of dependent(Required)

Please indicate type of treatment ?(Required)

In the dropdown menu below, please select the most appropriate category of disease, disorder or condition that the above consultation, treatment or diagnosis relates to:(Required)

Please provide the specific name of the medical condition that the above consultation, treatment or diagnosis relates to and what future treatment is required for this condition?

Date of Treatment/Consultation(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider*

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

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

Which dependent on your policy does your answer to question 1 relate to ?(Required)

Name and surname

ID or Passport number of dependent(Required)

Please indicate type of treatment ?(Required)

In the dropdown menu below, please select the most appropriate category of disease, disorder or condition that the above consultation, treatment or diagnosis relates to:(Required)

Please provide the specific name of the medical condition that the above consultation, treatment or diagnosis relates to and what future treatment is required for this condition?(Required)

Date of Treatment/Consultation(Required)

Telephone number of attending medical provider*

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

Details for Question 2

Which dependent on your policy does your answer to question 2 relate to ?(Required)

Name and Surname

ID or Passport number of dependent(Required)

In the dropdown menu below, please select the most appropriate category of disease, disorder or condition for which admission to a hospital or day clinic is required:(Required)

Please provide the specific name of the medical condition and/or diagnosis that requires treatment

Name of the attending medical provider

Telephone number of attending medical provide

What date is the admission booked for?*(Required)

Please provide any further details regarding the expected treatment

Details for Question 3

Which dependent on your policy does your answer to question 3 relate to ?(Required)

Name and Surname

ID or Passport number of dependent(Required)

Please indicate type of treatment(Required)

Name of the attending medical provider

Telephone number of attending medical provider

Date of your last consultation*(Required)

In the dropdown menu below, please select the most appropriate category of disease, disorder or condition for which admission to a hospital or day clinic is required:(Required)

Please provide the specific name of the medical condition that is being treated and what future treatment is required for this condition ?