KaeloGap 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 *

I do not currently have Gap Cover

I currently have Gap Cover with another provider but I wish to transfer my cover to Kaelo Gap

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 *

Single Policy - If you are joining 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.

Family Policy - 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. 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 of dependants. Premiums are payable monthly.

VAS

Value Added Services - Kaelo Lifestyle and extra by Dis-Chem

Plan Option

Kaelo Gap

Kaelo Gap Core

Cover Start Date *

First Name *

Surname *

ID Number *

Cellphone *

Gender *

Date of Birth *

Email *

Date of Employment

Address *

Address

City

Province

Postal Code

Address

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 up to the maximum age of 25. Cover for children only applies until they reach the age of 26 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

First Name

Surname

Relationship

Date of birth/ID number

Inception Date

Add Remove

Waiting Periods

A 3 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 26. Should any changes be required, you will notify Kaelo within one calendar month. This includes the addition or removal of Dependants

Account Name

Account Number

Branch Name

Bank Name

Account Type

Bank Code

Debit Order Date: Last Working Day of the Month

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.

Proof of Banking Details

Maximum file size: 5MB

Bank statement not older than 3 months or a letter from your bank.

Premium Payer Signature

Clear

Broker Details

Broker House Name

Broker Consultant Name *

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

Full Name *

I,(full name)

hereby 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 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 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.

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.

Centriq Concent

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 *

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