SAMANCORE DEMO

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

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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:
- Your cell phone to receive an OTP via sms
- If applicable, your spouse’s ID number (or passport number)
- If applicable, the birthdates of your children
- The benefit option of your medical scheme that you are covered on
- Name of the advisor who advised you on this policy application
Title*
Name and Surname*
First Last
Email*
Enter Email Confirm Email
Cellphone number*
Alternative telephone number
Form of identification*
- South African Identity Number
- Passport Number
ID No*
Passport No.*
Date of Birth*
Gender*
Address*
Street Address Address Line 2 City Province Postal Code Country
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Please select the correct status below for your application:*
- My employer has a group scheme with Cinagi and I am joining the group scheme where my employer will deduct the monthly premiums from my salary.
Current Employer :*
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What is your employee number?*
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When did your employment start?*
Name of the advisor on this policy application
First Last
Name of Brokerage
Advisor's email address
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Advisor's cellphone number
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Please enter your existing Cinagi policy number*

If you do not know your current policy number please get in touch with us. https://www.cinagi.co.za/contact/
Commencement Date of Your Policy*
Please note that your policy can only commence on the 1st day of a month
I hereby confirm my application for the following policy*
Protection of Personal Information Act (POPIA) Declaration*
I agree to the POPIA Declaration
By providing the information in this application form and applying 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. You also agree that we may 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. Your personal information will be stored in a secure encrypted manner and will not be sold or disseminated to any third party without your explicit consent. Additional detail regarding the use of personal information is set out in the Disclosure Notice that will accompany your policy document.

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Enter the OTP sent to your cellphone*

To verify your cell number, we have sent you a 6-digit One-Time-Pin via SMS – please enter the OTP above. If you have not received it, please click on the back button below and navigate back to this page to trigger a resend.
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.
Description of Dependant Types :
Spouse – this includes a common-law spouse or life partner
Children - includes stepchildren
Notes on Child Dependants
- A maximum of two children will be charged on your policy until they are 24 years old.
- Adult premiums will apply to all children on your policy as from age 24 onwards.
- There is no maximum age for children to stay on your policy, as long as they are registered on the same medical scheme membership as you are.
- Once they resign from your medical scheme membership, then they would need to apply for their own Cinagi policy.
Other Dependants – dependant types covered on your medical scheme that are not your spouse and/or children (eg parents) will need to apply for their own Cinagi policy
Medical Scheme*
Membership Number*
Commencement date of medical scheme membership*
Benefit Option*
The correct premiums and policy cover are determined by your benefit option – it is very important that you select the correct benefit option above.
Confirmation*
I confirm that the benefit option I have selected above is correct.
Please indicate what dependants are to be added to this policy
- Spouse
- Children
How many children are to be added to cover?*
Confirmation*
- I confirm that these dependants and myself are all registered on the medical scheme membership provided above.

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Details of Spouse
Title*
Name*
First Name Surname
Form of identification*
- South African Identification Number
- Passport Number
ID No*
Passport No*
Date of Birth*
Gender*
Would you like us to copy your spouse on all Cinagi e-mail and sms communications sent to you?*
- Yes
- No
Your spouse's cellphone number*
Your spouse's email address*
Details of your Children
Child's Name*
First Name Surname
Child's Date of Birth*
Child's Gender*
2nd Child's Name*
First Name Surname
2nd Child's Date of Birth*
2nd Child's Gender*
3rd Child's Name*
First Name Surname
3rd Child's Date of Birth*
3rd Child's Gender*
4th Child's Name*
First Name Surname
4th Child's Date of Birth*
4th Child's Gender*
5th Child's Name*
First Name Surname
5th Child's Date of Birth*
5th Child's Gender*
6th Child's Name*
First Name Surname
6th Child's Date of Birth*
6th Child's Gender*

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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.
Disclosure of Relevant Information*
I have read and understood the below warranty and agree to it.*
I warrant and declare that all the information in this application form 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 understand that I am also completing these questions on behalf of my dependants and that I have the necessary knowledge and authority to share such information with Cinagi.
Consent to Access Medical Records and Personal Information*
I have read and understood the below consent and agree to it.*
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.
Please answer all the questions below :
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?*
- Yes
- No
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?*
- Yes
- No
Question 3: Do you or any dependant currently: take any ongoing medication, and/or receive any other ongoing treatment for any medical condition?*
- Yes
- No
Details for Question 1
Please provide the details below in relation to your answer to Question 1:
Which applicant does this relate to?*
Please indicate type of treatment*
Date of Treatment / Consultation*
DD slash MM slash YYYY
Name of the attending medical provider*
Telephone number of attending medical provider*
Name of radiologist (if applicable)
Telephone number of radiologist (if applicable)
Please provide any further details regarding the treatment, advice or diagnosis received*
Does Question 1 also apply to another applicant?*
2nd Set of Details for Question 1
Please provide the details below in relation to your answer to Question 1 for the second person:
Which applicant does this relate to?*
Please indicate type of treatment*
Date of Treatment / Consultation*
DD slash MM slash YYYY
Name of the attending medical provider*
Telephone number of attending medical provider*
Name of radiologist (if applicable)
Telephone number of radiologist (if applicable)
Please provide any further details regarding the treatment, advice or diagnosis received*
Does Question 1 also apply to another applicant?*
3rd Set of Details for Question 1
Please provide the details below in relation to your answer to Question 1 for the third person:
Which applicant does this relate to?*
Please indicate type of treatment*
Date of Treatment / Consultation*
DD slash MM slash YYYY
Name of the attending medical provider*
Telephone number of attending medical provider*
Name of radiologist (if applicable)
Telephone number of radiologist (if applicable)
Please provide any further details regarding the treatment, advice or diagnosis received*
Does Question 1 also apply to another applicant?*
4th Set of Details for Question 1
Please provide the details below in relation to your answer to Question 1 for the fourth person:
Which applicant does this relate to?*
Please indicate type of treatment*
Date of Treatment / Consultation*
DD slash MM slash YYYY
Name of the attending medical provider*
Telephone number of attending medical provider*
Name of radiologist (if applicable)
Telephone number of radiologist (if applicable)
Please provide any further details regarding the treatment, advice or diagnosis received*
Does Question 1 also apply to another applicant?*
Our online application form can only facilitate a maximum of 4 applicants’ answers to a medical question. Please continue to complete this application and once we have received it, we will contact you in order to obtain the additional medical answers that you wish to provide for the 5th applicant on your policy. Please note that your policy application will not be activated until we have received this additional information.
Details for Question 2
Please provide the details below in relation to your answer to Question 2:
Which applicant does this relate to?*
Please describe the diagnosis and/or condition*
Name of the attending medical provider*
Telephone number of attending medical provider*
When is the admission expected?*
What date is the admission booked for?*
DD slash MM slash YYYY
Please provide any further details regarding the expected treatment*
Does Question 2 also apply to another applicant?*
2nd Set of Details for Question 2
Please provide the details below in relation to your answer to Question 2 for the second person:
Which applicant does this relate to?*
Please describe the diagnosis and/or condition*
Name of the attending medical provider*
Telephone number of attending medical provider*
When is the admission expected?*
What date is the admission booked for?*
DD slash MM slash YYYY
Please provide any further details regarding the expected treatment*
Does Question 2 also apply to another applicant?*
3rd Set of Details for Question 2
Please provide the details below in relation to your answer to Question 2 for the third person:
Which applicant does this relate to?*
Please describe the diagnosis and/or condition*
Name of the attending medical provider*
Telephone number of attending medical provider*
When is the admission expected?*
What date is the admission booked for?*
DD slash MM slash YYYY
Please provide any further details regarding the expected treatment*
Does Question 2 also apply to another applicant?*
4th Set of Details for Question 2
Please provide the details below in relation to your answer to Question 2 for the fourth person:
Which applicant does this relate to?*
Please describe the diagnosis and/or condition*
Name of the attending medical provider*
Telephone number of attending medical provider*
When is the admission expected?*
What date is the admission booked for?*
DD slash MM slash YYYY
Please provide any further details regarding the expected treatment*
Does Question 2 also apply to another applicant?*
Our online application form can only facilitate a maximum of 4 applicants’ answers to a medical question. Please continue to complete this application and once we have received it, we will contact you in order to obtain the additional medical answers that you wish to provide for the 5th applicant on your policy. Please note that your policy application will not be activated until we have received this additional information.
Details for Question 3
Please provide the details below in relation to your answer to Question 3:
Which applicant does this relate to?*
Please indicate type of treatment*
Name of the attending medical provider*
Telephone number of attending medical provider*
Date of your last consultation*
DD slash MM slash YYYY
Please provide further details regarding the above treatment*
Does Question 3 also apply to another applicant?*
2nd Set of Details for Question 3
Please provide the details below in relation to your answer to Question 3 for the second person:
Which applicant does this relate to?*
Please indicate type of treatment*
Name of the attending medical provider*
Telephone number of attending medical provider*
Date of your last consultation*
DD slash MM slash YYYY
Please provide further details regarding the above treatment*
Does Question 3 also apply to another applicant?*
3rd Set of Details for Question 3
Please provide the details below in relation to your answer to Question 3 for the third person:
Which applicant does this relate to?*
Please indicate type of treatment*
Name of the attending medical provider*
Telephone number of attending medical provider*
Date of your last consultation*
DD slash MM slash YYYY
Please provide further details regarding the above treatment*
Does Question 3 also apply to another applicant?*
4th Set of Details for Question 3
Please provide the details below in relation to your answer to Question 3 for the fourth person:
Which applicant does this relate to?*
Please indicate type of treatment*
Name of the attending medical provider*
Telephone number of attending medical provider*
Date of your last consultation*
DD slash MM slash YYYY
Please provide further details regarding the above treatment*
Does Question 3 also apply to another applicant?*
Our online application form can only facilitate a maximum of 4 applicants’ answers to a medical question. Please continue to complete this application and once we have received it, we will contact you in order to obtain the additional medical answers that you wish to provide for the 5th applicant on your policy. Please note that your policy application will not be activated until we have received this additional information.

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Consent for my Employer to Deduct Premiums*
I accept and understand
Your premium will be deducted from your salary each month by your employer and will show on your payslip. It is very important that you ensure that such deductions are made, so please check your payslip to ensure that the premium is being deducted and that it is the correct amount.
Bank Details
Please confirm your banking details below for the monthly debit order deduction – deductions are made in advance on the 1st day of each month:
Bank Name*
Account Holder Name*
Account Type*
Account Number*
Branch Code*
Your monthly premium will be
Debit Order Authority & Mandate*
I, accept and understand
I acknowledge that by accepting this Authority and Mandate I am bound by the payment terms applicable to this policy agreement. I authorise Cinagi on behalf of Infiniti Insurance Limited to draw all monthly premiums due on this policy against the above bank account on the 1st day of each month. I authorise Cinagi on behalf of Infiniti Insurance Limited to re-present a payment instruction against the above account in the event that any payment is unsuccessful to meet my obligations under or in terms of this Agreement. I authorise Cinagi on behalf of Infiniti Insurance Limited to obtain any information about me/us from any credit bureau, life assurance or credit providers' industry association or any other information related to credit history, judgement history or default history.
Previous Gap Cover
Please note that the application of waiting periods on your policy will depend on you providing us with sufficient evidence of your previous cover.
Do you currently have gap cover with another provider?*
- Yes
- No
Name of the other gap cover provider?*
When did this policy commence?*
DD slash MM slash YYYY
Policy Number*
When does or did the cover on this policy end?*
DD slash MM slash YYYY

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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:
1. 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.
2. The information above provided by me and my dependents is true, honest and accurate and I have disclosed all material information to Cinagi.
3. I have not withheld any information which may be material to the assessment of risk under this policy.
4. 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.
5. 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, my spouse and/or children (if applicable).
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.
11. 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).
12. I hereby authorise Cinagi to process and store my own and my dependents’ personal information for the purpose of administering this policy.
13. I hereby give my financial adviser and the brokerage that employs them authority to deal with this policy application form on my behalf as well as authority to deal with my policy once it is activated.
14. 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*
I agree
Name
This field is for validation purposes and should be left unchanged.

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Details for Question 1

2nd Set of Details for Question 1

3rd Set of Details for Question 1

4th Set of Details for Question 1

Details for Question 2

2nd Set of Details for Question 2

3rd Set of Details for Question 2

4th Set of Details for Question 2

Details for Question 3

2nd Set of Details for Question 3

3rd Set of Details for Question 3

4th Set of Details for Question 3

Bank Details

Previous Gap Cover