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Name:
*
Surname:
*
Age:
*
Contact Number:
*
Email Address:
*
Income bracket:
*
Select Income Bracket
< R126,000
R126,000 - R138,000
R138,000 - R176,400
> R176,400
Age of principal member:
*
Number of adult dependants:
*
None
1
2
3
4
5
6
7
8
9
10
Number of child dependants:
*
None
1
2
3
4
5
6
7
8
9
10
Are you currently a member of a medical scheme:
*
No
Yes
Name of current medical scheme:
Period with this scheme:
Less Than 2 Years
More Than 2 Years
Marital Status:
*
Single
Married
Do you or any of your dependants take chronic medication:
*
No
Yes
What is the average monthly cost of your chronic medication:
Terms & Conditions
* Please note the quoted amount is an estimate only and excludes Late Joiner Penalties, should they apply.
* Please note these are the contributions for 2012 and if you need information regarding 2011 contributions please contact our Call Centre on 0861 497 497
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