Registration process
 
  1. Please complete the online or downloadable application form.
  2. You will receive an email, SMS or telephonic confirmation acknowledging receipt of your application.
  3. Applications received after the 23rd of any month will be processed as usual, however, due to debit order cut-off times, policy inception date is likely to be in the month following the upcoming month.
  4. Welcome packs are sent by mail.
  5. Please feel free to contact us by email at admin@essentialmed.co.za or call on 0861 632 123 if you have any queries regarding your application.
 

To register for Essential Med medical insurance
 

Apply for your policy by simply completing the Online Application below or click here to Download Application Form
 
All fields marked with an asterisk * are compulsary.
 

Online Application Form
 

Where did you hear about Essential Med ? *

Please Tick
 

Essential Med Agent

Promotional Email

Google Search

Facebook

SMS Campaign

Newspaper

Magazine

Radio

TV

Word of mouth

Other
 

1: Personal Information (Primary Applicant)
 

Title*

Names*

Gender*

Street Address*
 

Suburb

Town*

Postal Code*

E-mail

ID Number*
  Please note that we have a maximum
entry age of 55.

Marital Status*

Initials*

Surname*

Postal Address
 
 

Town

Postal Code
 

Contact Details:

Home

Work*

Cell*

Fax
 

1.2: Employment Information
 

Employee No

Company Name

Monthly Income
 

2: Dependants - Dependants of the Primary Applicant
 

Definition:

Spouse/Partner: A person to whom the principal applicant is either married or has a committed and serious relationship with, similar to that of a marriage in which there is mutual financial and emotional support and a shared household, irrespective of the gender of either party.

Dependants: Children or other immediate family members in respect of whom, the principal member is liable for care and support. Maximum age of child dependant is 21, unless the dependent child is studying full time or is mentally or physically handicapped and fully dependent on the principal applicant.

Please note: If you do not have your dependant(’s) ID number(s), please provide their date of birth in the ID Number field as follows: DDMMYYYY
 

2.1: Names

Surname

Initials

Title

Gender

Relationship

ID Number
 
 

2.2: Names

Surname

Initials

Gender

Relationship

ID Number /
Date of Birth
(DDMMYYYY)
 
 

2.3: Names

Surname

Initials

Gender

Relationship

ID Number /
Date of Birth
(DDMMYYYY)
 
 

2.4: Names

Surname

Initials

Gender

Relationship

ID Number /
Date of Birth
(DDMMYYYY)
 
 

2.5: Names

Surname

Initials

Gender

Relationship

ID Number /
Date of Birth
(DDMMYYYY)
 

3: Beneficiary - Death Benefit
 

Name

Surname

ID Number

Gender

Contact No.
 

4: Additional Information
 

4.1: Currently receiving treatment on any medical / dental condition?

If the answer to any of these questions is YES, please complete section 5 below with relevant information.
 

4.2: Concerned about / aware of any condition which may require medical / dental attention?
 

4.3: Currently use any medication?
 

4.4: Pregnant?
 

4.5: Undergone any major operations in the last 5 years?
 

4.6: Are you or your spouse a member of a medical scheme or a hospital plan?
 

5: Existing Medical Conditions / Events / Medical Schemes or Hospital Insurance Plans
 

Note that all hospital benefits and claims arising from a known pre-existing condition are excluded for a minimum period of 24 months.
 

Name 1

Existing medical scheme information
 
 

Name 2

Condition / Event
 
 

Name 3

Condition / Event
 
 

Name 4

Condition / Event
 

6: Membership Options and Pricing
 

Members Covered

Preventative
Day to Day

Please
Tick

Hospital Plan
Benefit Only

Please
Tick

Day to Day & Hospital Plan

Please
Tick
 

Single

R285

R335

R520

Including 1 child

R395

R365

R675

Including 2 children

R515

R395

R815

Including 3 children

R600

R415

R945

Including 4 children

R645

R445

R960
 
 

Couple

R455

R590

R985

Including 1 child

R570

R645

R1 135

Including 2 children

R680

R690

R1 265

Including 3 children

R780

R700

R1 395

Including 4 children

R855

R735

R1 430
 

7: Doctor's Details
 

Please provide your current GP's details.

Name of Doctor:

Area:

Tel. No.:

Practice No.:

 

8: Debit Order Instruction
 

I / We hereby request "instruct" and authorize you / payroll master to draw / deduct from my / our account / salary with the below mentioned bank (or any other bank or branch to which I / We my transfer my / our account) the amounts (as indicated in point 8.1) or any other variable amount pertaining to this agreement. This being the amounts necessary for the settlement in respect of my / our purchases / agreement. These withdrawals from my / our bank account by you shall be treated as though it has been signed by me / us personally.

8.1: Policy Premium

on the

of

I / we understand that if the debit order action date falls on a non banking day that the debit order may be actioned on the banking day preceding the debit order action date.

I / We understand that the withdrawal hereby authorized will be processed by Insurance Outsource Managers (Pty) Ltd, and I / we also understand that the details of each withdrawal will be printed on my bank statement or on an accompanying voucher. I / We agree to pay any bank charges relating to this debit order instruction.

This authority may be cancelled by me / us by giving you thirty days notice in writing, sent by prepaid registered post. I / we understand that I / we shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force if such amounts were legally owing to you. Receipt of this instruction by you shall be regarded as receipt thereof by my / our bank (whichever it is or will be).

ASSIGNMENT: I / We acknowledge that the party hereby authorized to effect the drawing (s) against my / our account may not cede or assign any of its rights to any third party without my / our prior written consent. I / we may not delegate any of my / our obligations in terms of this contract authority to any third party without prior written consent of the authorized party.
 

Nominated Bank and Account details:
 

Bank Name

Account Type

Branch Name

Branch Code

Account No

Name of account holder
 

9: Acknowledgement
 
  1. I warrant that I have been provided with all the intermediatery, insurance and benefit details, or any other information as I may have requested.
  2. I warrant that all details and facts herein are accurate and properly disclosed, even if completed by the intermediary or representative on my behalform.
  3. I understand that the benefits offered are risk benefits only, and that there are no surrender values.
  4. Failure to pay premiums will result in benefits lapsing.
  5. In the event of any query regarding this policy or any other claim in terms of this policy, I consent to the disclosure of any relevant information to the intermediary or any Essential Med or Day 1 official for the purpose of resolving the query.
  6. In the event of no nominated beneficiary, I agree that the benefit be payable to the first claimant with reasonable title to claim any benefit.
  7. I acknowledge that the Health Care Plan is not a Medical Aid and that the benefits are not equivalent to that of a medical aid.
  8. I am satisfied that the plan chosen by me best suits my needs.
 

Applicant:
 

Initials and Surname*

Application Date
 

Details of Intermediary (For Brokers Only)
 

Brokerage Name

Brokerage Code

Consultant Initial & Surname

Consultant Code
 

Authorization Code*
 

Please re-enter the Authorization Code as seen below:
 

Consent to process application*

I hereby authorise Essential Med to process this Application and deduct the monthly premiums due via Debit Order.

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