Western Gap Shortfall Cover

Western Gap Corporate Policyholder Application Form

Western Gap Corporate Policyholder Application Form
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 Western Gap email address: western@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 Western Gap, please submit your proof of cover. Waiting periods may apply.
Maximum upload size: 33.55MB
Plan Type *
Include Oncology Supplementary Buy-up
Address *
Address
City
Province
Postal Code
Employer Details

Dependant Details

Should you have Dependants, please provide us with a copy of your Medical Scheme membership certificate. If any of your Dependants are on another Medical Scheme, please provide a copy of their membership certificate.

Waiting Periods

A 3 month General Waiting Period and a 10 month Maternity Specific Waiting Period may be applied. The following procedures will have a 6 month Waiting Period applied: joint surgery, nasal and sinus surgery, tonsillectomy, adenoidectomy, grommets, endoscopic and arthroscopic procedures, hernia repairs, hysterectomy, cardiac surgery, spinal surgery, dentistry and cataract procedures. Previously diagnosed cancer, within a period of 12 months preceding the date of inception, will be regarded as a pre-existing condition and Oncology Cover will be excluded for 12 months.

Debit Order Details

If you are responsible for the payment of your Premium as part of an employer group, please complete the below section. If your employer is contributing the Premium on your behalf, please do not complete this section.
Debit Order Date
Please note Premiums are due in arrears.

Broker Details

If applicable, the Broker Fee form must be read in conjunction with this application form.

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 upload size: 33.55MB
A clear copy of the Medical Scheme Membership Certificate is required. *
Maximum upload size: 33.55MB

Declaration

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 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 Western 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 applicable, I hereby authorise Western to draw against the above bank account all amounts due to Western in terms of this insurance cover. Should the relevant Premiums be adjusted by the Underwriters, I hereby confirm that the adjusted amount may be drawn from the above account subject to the notice period outline in the Policy. This request is to remain in force unless cancelled by one month's written notice. 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 Western. I accept that any notice given to my employer is deemed to have been given to me.

Sharing of Insurance Information

Insurers share information with each other regarding policies and claims with a view to prevent fraudulent claims and obtain material information regarding the assessment of risks proposed for insurance. By reducing the incidents of fraud and assessing risks fairly, future premium increases may be limited. This is done in the public interest and in the interest of all current and potential policyholders.

The sharing of information includes, but is not limited to information sharing via the Information Data Sharing System operated by TransUnion ITC on behalf of the South African Insurance Association. By accepting or renewing this insurance, you or any other person that is represented herein, gives consent to the said information being disclosed to any other insurance company or its agent.

You also similarly give consent to the sharing of information in regards to past insurance policies and claims that you have made. You also acknowledge that information provided by yourself or your representative may be verified against any legally recognised sources or databases.

By accepting or renewing this insurance, you hereby consent to such information sharing with regards to underwriting or claims information that you have provided or that has been provided by another person on your behalf.

In the event of a claim, the information you have supplied with your application together with the information you supply in relation to the claim, will be included on the system and made available to other insurers participating in the Information Data Sharing System.

Sharing of insurance information is done in accordance with applicable legislation, as well as our Privacy Notice which can be found on our website: www.kaelo.co.za.

Use of Your Personal Information

When you enter into this policy you will be giving us your personal information that may be protected by data protections legislation, including but not only, the Protection of Personal Information Act, 2013 (“POPI”). We will take all reasonable steps to protect your personal information.
You authorise us to:

  1. Process your personal information to
    • Communicate information to you that you ask us for.
    • Provide you with insurance services.
    • Verify the information you have given us against any source or database.
    • Compile non-personal statistical information about you.
  2. Transmit your personal information to any affiliate, subsidiary or re-insurer so that we can provide insurance services to you and to enable us to further our legitimate interests including statistical analysis, re-insurance and credit control.
  3. Transmit your personal information to any third party service provider that we may appoint to perform functions relating to your policy on our behalf.

You acknowledge that this consent clause will remain in force even if your policy is cancelled or lapsed.

Processing of your personal information is always done in accordance with applicable legislation, as well as our Privacy Notice which can be found on our website: www.kaelo.co.za.

Signature

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).
Underwritten by Western National Insurance Company Limited (FAIS: Juristic Representative under FSP no 9465).

Western Rethink Insurance
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