Liberty Gap Cover Online Staff Application

Product
Selection

Personal
Details

Medical
Details

Declaration

Payment

Finish
Product Selection
Gap Option*
Select the product that you require:
Type of Policy*
Type of Policy (Optimal)*
Optional Extended Benefits*
Select any additional cover that you require. These extended benefits expire at age 65 and a 6 month waiting period applies.
Have you or any of your dependants on your medical aid ever had any form of cancer, cancerous growths, tumours, lumps or malignant moles?*
Please ensure that your answer is accurate. Should your answer be untruthful or inaccurate it may lead future claims being declined.
Total Premium
Please note: Premiums are valid for 2024. Prices to increase 1 Jan 2025.

Product
Selection

Personal
Details

Medical
Details

Declaration

Payment

Finish
Medical Aid Details
Are you currently a member of a registered South African medical aid?*
Current Medical Scheme and Option*
Total number of people on your medical aid*
You will not be entitled to claim a benefit for a period of 12 months from the start date of your policy in respect of a medical condition for which in the 12 months preceding the start date of your policy medical advice, diagnosis, care or treatment was received or would reasonably have been recommended. If you fall pregnant before the start date of your policy this will be regarded as a pre-existing condition and any pregnancy and birth-related claims will be excluded for a period of 12 months from the start date of your policy. If, immediately before the start date of this policy, you were insured under a medical expense shortfall policy with similar benefits to this policy, then the pre-existing condition waiting period will only be applied to the unexpired part of the pre-existing condition waiting period in the previous policy. The pre-existing condition waiting period will apply for a period of 12 months for any benefit not provided under your previous medical expense shortfall policy.

Product
Selection

Personal
Details

Medical
Details

Declaration

Payment

Finish
Payment
TOTAL PREMIUM: R{Hidden Total Premium:9} pm
The above premium includes:
- {Medical Gap Option:5}
- {Type of Policy:6}{Type of Policy:174}
- {Optional Extended Benefits:7}
Authorisation*
- I hereby authorise Zestlife to issue payment instructions to its bank to collect the above monthly premium due by debit order from my bank.
Full names of account holder*
Surname of account holder*
Form of Identification of account holder*
- South African ID Number
- Passport Number
ID number of account holder*
Passport number of account holder*
Country that issued account holder's Passport*
Country
Bank Name*
Branch Code*
Account Number*
Account Type*
When would you like the policy to start? (The policy start date must be on the 1st day of a future month.)*
DD dash MM dash YYYY
What day of the month must premiums be collected?*
Will the following application replace an existing policy?*
Name of current insurer*
I/we declare that I/we have read and understood the terms and conditions stated and agree to be bound to them. By completing and submitting the form I/we attest that the information given on this application form is true and correct.
Name*
First name Surname
Declaration and Signature*