Medshield Medical Aid Application

There are 2 parts of the application - PLEASE COMPLETE AND SEND ME BOTH!!

CHOOSE EITHER

PLAN A PART 1 AND PART 2 (Please note there is a 12-month pre-existing condition exclusion with the Top Up).

OR

PLAN B PART 1 AND PART 2 (Please note there is a 12-month pre-existing condition exclusion with the Top Up).

OR

MEDIBONUS

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PART 1 - MEDSHIELD MEDICAL AID

Please complete;

• Page 1 - Your plan, Start Date and Total premium

• Page 2 - SECTION A - Your details

  SECTION B - Souse or adult dependants

• Page 3 - SECTION 3 - Any previous medical aid membership (supply proof)

  SECTION D - Medical question to answer YES or NO.
  Please give as much information as possible - use extra page if need be. (ESPECIALLY IF YOU ARE PREGNANT)

• Page 4 - SECTION E - Debit order details (supply proof) SIGN

• Page 5- SECTION G - Employer details (ONLY IF EMPLOYER TO PAY PREMIUMS)

  DECLARATION - SIGN and DATE

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WHEN COMPLETED PLEASE FAX TO;

0866 688 122

Please phone me to discuss your concern.

083 377 88 93

Email: pyburn@peterpyburn.co.za

Don't leave your concern here. Call me for advice - no obligation!