Upgrade Policy

Upgrade My Policy Benefits

For us to upgrade your policy benefits to Gap ^MAXwe will require a few of your personal details as well as that of your dependents you would like to have covered on your Cinagi policy.

You can view the Gap ^MAX benefits and comparison with Gap ^CORE HERE!

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
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.

Name and Surname(Required)

Name Surname

ID or Passport number(Required)

Date of Birth(Required)

Cinagi Policy Number

Email(Required)

Enter Email Confirm Email

Cell Phone

Medical Scheme(Required)

Medical Scheme Benefit Option(Required)

Medical Scheme Membership Number

Spouse Dependant(Required)

Name(Required)

First Last

Date of Birth(Required)

Date of birth of spouse dependant

ID or Passport number

Id number or passport of spouse dependant

Child Dependant/s(Required)

Child Dependents

Name	Date of Birth	ID or Passport number	Actions

There are no Entries.

Are you or any of your dependants aware of any condition or illness that could result in hospitalisation in the next 12 months ?

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.
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.