Title

First name

Surname

ID Number

Telephone no.

Facsimile no.

Cellphone no.

E-mail address

Postal Address

Postal Code

Province

Employer

Employment Sector

Private State

Subsidy

Yes No      If Yes Percent

Details of Current Medical Aid Scheme

Name of Medical Scheme

Which Option?

Monthly Contribution

Are you interested in a specific Selmed option?

How Many People in your Family?

Member

Spouse

Dependants over 21

No. of children under 21

Chronic Medicine Users

Number of chronic users in family

Cost of chronic medicine per month

Chronic conditions / specify

Day-to-Day Benefits (e.g. doctors and acute medicine)

Required

Yes No 

Monthly Amount

If you and/or you spouse or partner are over 34 years of age, please complete the following.

On a medical scheme before 1/4/2001 to date?

Yes No 

Have you previously belonged to a medical scheme as an adult?

Yes No 

If YES, years in total

Name of scheme(s)

Any further requests or comments