This application form is only for SAMANCOR CHROME employees and cannot be used by other employer groups. For our standard online application form, please click here
This application form can be used to join your employer’s group scheme or to join in your private capacity.
Please note that you will need the following in order to complete this application form:
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.