Kaelo Gap | Gap cover
Insured by Centriq Insurance

Individual Policyholder Application Form

Kaelo Gap Individual Policyholder Application Form 2022 / 2023

IMPORTANT NOTE: Please complete and sign this form. Kaelo will only accept applications received by a broker. Applications received after the 15th of the current month will only activate the 1st of the following month.
Dedicated Kaelo Gap email address: kaelogap@kaelo.co.za.

Applicant Details

Please indicate the status of your application by selecting the relevant option below *
If you have Gap Cover with another provider but wish to transfer to Kaelo Gap, please submit your proof of cover. Waiting periods may apply. *

Maximum file size: 67.11MB

Policy Type *
Plan Option
Plan Add-on
Address *
Address
City
Province
Postal Code
Country

Insured Party Details

Should you have dependants, please provide us with a copy of your Medical Scheme membership certificate. Cover will apply to you, your spouse and your children. Cover for children only applies up to the age of 25 years. If any of your dependants are on another Medical Scheme, please provide a copy of their membership certificate.

Please complete for the main member and all dependants

Waiting Periods

A three-month General Waiting Period and 12-month Condition-Specific Waiting Period will be applied for all new applications. If you are transferring your cover from another Gap Cover provider with similar benefits, only the balance of the applicable waiting periods will apply.

Debit Order Details

You will see the following reference on your bank statement: KAELOGAP. If you are joining as a family, you accept that cover will apply to you, your spouse and your children up to the maximum age of 25. Should any changes be required, you will notify Kaelo within one calendar month. This includes the addition or removal of dependants.

Debit Order Date: Last Working Day of the Month
R

Please note Premiums are due in arrears.

I, the Premium payer, 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 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.

Maximum file size: 5MB

Please submit a copy of your bank statement or a bank confirmation letter not older than three months with this form.

Broker Details

Mandatory Documents

Please ensure that the following documents are submitted with your application form
A clear copy of either the ID or birth certificate of all Insured Parties being registered. *

Maximum file size: 67.11MB

A clear copy of the Medical Scheme membership certificate is required. *

Maximum file size: 67.11MB

Declaration

I,(full name)

declare that this application form, whether in my handwriting or not, is accurate and complete and forms the basis of the contract of insurance between the Insurer and myself. I apply for the insurance product/s and agree to abide by its Policy rules and/or those of its Insurer and any amendments which may be made from time to time. I confirm that all the information provided is complete and true and that I have not concealed any relevant 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, 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 provide irrevocable authority for Kaelo and its Insurer to obtain any of my or my dependant's medical history from any healthcare provider, Medical Scheme, insurance company or healthcare broker to assess this application for insurance and 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. If any Policy Benefit becomes payable after or as a result of my death, I 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.

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For further information please read our Privacy Notice, which can be found on www.centriq.co.za.

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