Western Gap Individual Policyholder Application Form

A 3 month General Waiting Period and a 10 month Maternity Specific Waiting Period will 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.

Please note Premiums are due in advance.

Please ensure that the following documents are submitted with your application form.

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.