Personal Details (Principal Member)
Title: Surname:
First Names:
ID Number:
Date of Birth:
Employer:
Physical Address:
 
Postal Address:
 
Code:
Code:
Telephone: (w) (h)
Fax:
Cell:
E-mail:
Preferred Method of Communication:
Dependant(s) To Be Covered
Spouse:
ID Number:
Child 1:
ID Number:
Child 2:
ID Number:
Child 3:
ID Number:
Child 4:
ID Number:
Beneficiary
Name:
ID Number:
COVER: Single or Single + 1/2/3/4 COVER: Couple or Couple + 1/2/3/4 COVER: Senior Single or Senior Couple
Monthly Premium
Plan:
R150.00 Once-off Registration Fee will be Added to my First Monthly Premium
R
5% Increase 1st January each year
Additional Information
Are you or any of your dependants on any form of chronic medication?
Person:
Condition:
Medication:
Are you or any of your dependants receiving treatment for any other medical condition other than a chronic condition?
Person:
Condition:
Medication:
Are you or any of your dependants receiving treatment for any dental condition?
Person:
Condition:
Medication:
Are you or any of your dependants aware of any other current conditions, which may require medical or dental attention in the near future?
Person:
Condition:
Medication:
Are you pregnant?
Have you or any of your dependants undergone any major operations in the past 5 years?
Person:
Condition:
Medication:
Have you or any of your dependants been hospitalised in the past 5 years?
Person:
Reason for admission:
Date of admission:
Are you or your spouse a member of a medical scheme or hospital plan?
Person:
Name of scheme / plan:
Date of inception of policy:
I warrant that I have been provided with all the intermediary, insurers and benefit details, or any additional information as I may have requested and that all details and facts provided herein are accurate and properly disclosed, even if completed by the intermediary or a representative on my behalf. I understand that the hospital stated benefits plan offered are risk benefits only and that there are no surrender values. Failure to pay premiums will result in benefits lapsing. In the event of any query regarding this policy or any claim in terms of this policy, I consent to the disclosure of any relevant information to the intermediary or any Dayl Health (Pty) Ltd official for the purposes of resolving the query. In the event of no nominated beneficiary, I agree that necessary burial costs will be paid directly, or to the person who paid for such costs. Thereafter any remaining benefit will be payable to the first claimant with reasonable title to claim any benefits. I acknowledge that the Dayl Health (Pty) Ltd Insured Health Plan is not a Medical Aid. I acknowledge that Dayl Health (Pty) Ltd and the Insurer, where applicable, reserve the right to accept or decline an application based on information provided at the time of application.
Your chosen Network Provider (GP): Dr.
Banking Details I, the Account Holder, authorise SDL Benefit Services (Pty) Ltd to deduct the above premium from my bank account each month.
Name of Account Holder:
Name of Bank:
Date: Signature of Account Holder
(If not principal member)

Branch:
Branch Code:
Account Number:
Account Type:
Date: Signature of Principal Member

Inception Date:
Debit Order Date: