R30 000 18 – 64 R145, 00 R30 000 65 – 74 R230, 00 R30 000 75 - 84 R375, 00 FAMILY PLAN OPTIONS (MEMBER, SPOUSE AND CHILDREN) BENEFIT AGE CATEGORY PREMIUM S E L ECT X R10 000 18 – 64 R120, 00 R10 000 65 – 74 R165, 00 R10 000 75 - 84 R245, 00 R15 000 18 – 64 R130, 00 R15 000 65 – 74 R200, 00 R15 000 75 - 84 R315, 00 R20 000 18 – 64 R145, 00 R20 000 65 – 74 R235, 00 R20 000 75 - 84 R390, 00 R25 000 18 – 64 R160, 00 R25 000 65 – 74 R270, 00 R25 000 75 - 84 R452, 00 R30 000 18 – 64 R170, 00 R30 000 65 – 74 R305, 00 R30 000 75 - 84 R520, 00 POLICYHOLDERS DETAILS TITLE: INITIALS: SURNAME: FIRST NAMES: GENDER: ID NUMBER: AGE: DATE OF BIRTH: POSTAL ADDRESS STREET ADDRESS (IF DIFFERENT TO POSTAL ADDRESS) ** SELECT PREFERRED METHOD OF COMMUNICATION, THIS WILL BE TO RECEIVE POLICY DOCUMENTATION AS WELL AS GENERAL COM* TELEPHONE WORK: FAX: TELEPHONE HOME: EMAIL: TELEPHONE CELL: LANGUAGE: OCCUPATION: IMMEDIATE FAMILY DEPENDANTS (MAX 1 SPOUSE + 4 CHILDREN) SURNAME NAME IDENTITY NUMBER DATE OF BIRTH SPOUSE CHILD CHILD CHILD CHILD EXTENDED PLAN OPTIONS **COVER FOR EXTENDED FAMILY MEMBERS MAY NOT EXCEED THAT OF THE PRRINCIPAL MEMBER PLAN OPTION BENEFIT AGE CATEGORY PREMIUM SELECT X EXTENDED PLAN A1 R10 000 0 – 22 R45.00 EXTENDED PLAN A2 R10 000 23 – 65 R60.00 EXTENDED PLAN A3 R10 000 66 – 75 R100. 00 EXTENDED PLAN A4 R10 000 76 – 85 R160.00 EXTENDED PLAN A5 R15 000 0 – 22 R50.00 EXTENDED PLAN A6 R15 000 23 – 65 R70.00 EXTENDED PLAN A7 R15 000 66 – 75 R125.00 EXTENDED PLAN A8 R15 000 76 – 85 R215.00 EXTENDED PLAN A9 R20 000 0 – 22 R65.00 EXTENDED PLAN A10 R20 000 23 – 65 R85.00
R30 000 R30 000 R30 000 18 – 64 65 – 74 75 - 84 R145, 00 R230, 00 R375, 00 FAMILY PLAN OPTIONS (MEMBER, SPOUSE AND CHILDREN) BENEFIT R10 000 R10 000 R10 000 R15 000 R15 000 R15 000 R20 000 R20 000 R20 000 R25 000 R25 000 R25 000 R30 000 R30 000 R30 000 AGE CATEGORY 18 – 64 65 – 74 75 - 84 18 – 64 65 – 74 75 - 84 18 – 64 65 – 74 75 - 84 18 – 64 65 – 74 75 - 84 18 – 64 65 – 74 75 - 84 PREMIUM R120, 00 R165, 00 R245, 00 R130, 00 R200, 00 R315, 00 R145, 00 R235, 00 R390, 00 R160, 00 R270, 00 R452, 00 R170, 00 R305, 00 R520, 00 S E L ECT X POLICYHOLDERS DETAILS TITLE: INITIALS: SURNAME: FIRST NAMES: GENDER: ID NUMBER: AGE: DATE OF BIRTH: POSTAL ADDRESS STREET ADDRESS (IF DIFFERENT TO POSTAL ADDRESS) ** SELECT PREFERRED METHOD OF COMMUNICATION, THIS WILL BE TO RECEIVE POLICY DOCUMENTATION AS WELL AS GENERAL COM* TELEPHONE WORK: FAX: TELEPHONE HOME: EMAIL: TELEPHONE CELL: LANGUAGE: OCCUPATION: IMMEDIATE FAMILY DEPENDANTS (MAX 1 SPOUSE + 4 CHILDREN) SURNAME NAME IDENTITY NUMBER DATE OF BIRTH SPOUSE CHILD CHILD CHILD CHILD EXTENDED PLAN OPTIONS **COVER FOR EXTENDED FAMILY MEMBERS MAY NOT EXCEED THAT OF THE PRRINCIPAL MEMBER PLAN OPTION BENEFIT AGE CATEGORY PREMIUM SELECT X EXTENDED PLAN A1 R10 000 0 – 22 R45.00 EXTENDED PLAN A2 R10 000 23 – 65 R60.00 EXTENDED PLAN A3 R10 000 66 – 75 R100. 00 EXTENDED PLAN A4 R10 000 76 – 85 R160.00 EXTENDED PLAN A5 R15 000 0 – 22 R50.00 EXTENDED PLAN A6 R15 000 23 – 65 R70.00 EXTENDED PLAN A7 R15 000 66 – 75 R125.00 EXTENDED PLAN A8 R15 000 76 – 85 R215.00 EXTENDED PLAN A9 R20 000 0 – 22 R65.00 EXTENDED PLAN A10 R20 000 23 – 65 R85.00
flexi-plan-application-forms-new.docx