KaeloGap Continuation Form

Kaelo Gap Continuation Form 2022

IMPORTANT NOTE: Continuations received after the 15th of the current month will only come into effect the first of the following month.
Dedicated Kaelo Gap email address: kaelogap@kaelo.co.za.

Policy Number *

Effective Date

Policyholder Details

First Name *

Surname *

ID Number *

Cellphone: *

Gender

Date of Birth *

Email *

Address *

Address

City

Province

Postal

Policy Type and Continuation Premium

Policy Type *

Single Policy - R347.00

Family Policy - R494.00

If you are continuing as a single Policyholder, you accept that cover will only apply to yourself and that should any changes be required, you will notify Kaelo within 90 days. This includes the addition of dependants.
Premiums are payable monthly.

If you are continuing as a family, you accept that Cover will apply to you, your spouse and your children up to the maximum age of 25. Cover for children only applies until they reach the age of 26 years. Should any changes be required, you will notify Kaelo within 90 days. This includes the addition or removal of dependants. Premiums are payable monthly.

Debit Order Details

Account Name *

Account Number *

Branch Name *

Bank Name *

Account Type *

Bank Code

Debit Order Date: Last working day of the month

Premium *

Name and Surname of Premium Payer *

Please note Premiums are due in arrears.

I, the Premium payer, hereby authorise Centriq to draw against the above bank account all amounts due to Centriq in terms of this insurance cover. Should the relevant Premiums be adjusted, I hereby confirm that the adjusted amount may be drawn from the above account subject to the notice period outlined in the Policy. This request is to remain in force unless cancelled by one month's written notice.

Premium Payer Signature *

Clear

Broker Details

Broker House Name *

Broker Consultant Name *

Mandatory Documents

Please ensure that the following documents are submitted with your amendment/s:

Please upload a clear copy of either the ID or Birth Certificate of all Insured Parties being registered *

Maximum upload size: 2MB

A clear copy of the Medical Scheme Membership Certificate is required *

Maximum upload size: 2MB

Declaration

Full Name *

hereby declare that this continuation form, whether in my handwriting or not, is accurate and complete and forms the basis of the contract of insurance between the Underwriter and myself. I hereby apply for the insurance product/s and agree to abide by its Policy rules and/or those of its Underwriter and any amendments thereto which may be made from time to time. I confirm that all the information provided herein is complete and true and that I have not concealed any relevant or pertinent information that may affect the evaluation of risk considered under this Policy of cover. I understand that the provision of any false, misleading or missing information could result in my application being rejected or my Policy being cancelled or claims being rejected. Should this occur, I agree to refund all Benefit payments that I have received in relation to this Policy of insurance.

I hereby provide irrevocable authority for Kaelo and its Underwriter to obtain any of my or my beneficiaries' medical history from any Medical Service Provider, Medical Scheme, insurance company or healthcare broker for the purposes of assessing this application for insurance as well as the underwriting of any future risk or the assessment of any claim that relates to this insurance cover. Premiums due to Centriq are payable monthly. Premiums that are in arrears will result in my Policy being suspended or possibly terminated. In the event that any Policy Benefit becomes payable subsequent to or as a result of my death, I hereby provide an irrevocable authority for such Benefits to be paid directly to my surviving Spouse or failing such circumstance to the nominated guardians or trustees responsible for the future care of my minor Children or failing either of the preceding events to my estate. Where my employer deducts the Premium from my salary. I hereby provide authority for my employer to deduct such Premium and pay this across to Centriq. I accept that any notice given to my employer is deemed to have been given to me.

Centriq Content

I consent to Centriq Insurance, and its operators, processing, and further processing, my personal information in accordance with the Protection of Personal Information Act, for the purposes of concluding, and performing in terms of, this insurance contract. For further information please read our Privacy Notice, which can be found on www.centriq.co.za.

Signature *

Clear

Date *

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Kaelo Risk (Pty) Ltd is an authorised financial services provider FSP: 36931. Underwritten by Centriq Insurance Company Limited (“Centriq”), a licensed non-life insurer and authorised Financial Services Provider (FSP 3417).

Statutory notice:

This is not a medical scheme and the cover is not the same as that of a medical scheme.
This policy is not a substitute for medical scheme membership.

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