2012 Selfmed Medical Aid Quote

Should you wish to get an idea of what an Selfmed medical aid will cost, please complete the blocks below and send to me.

Your Details

Do you have to join your company medical aid?Company scheme Own

Your email address:
Your telephone/cell number:
Your name and surname:
Your Date of Birth:
Your partner's name and surname (if required) :
Your partner's Date of Birth:
Any OTHER Adult dependant's - if so, how many?
First child's name:
Child's Date of Birth:
Second child's name:
Child's Date of Birth:
Third child's name:
Child's Date of Birth:

Any other information we should know about?

Your current medical aid plan (if any): Please state the actual plan as well.

Would you like to receive my informative letter on personal financial matters? Yes

Please note:

• The submission of this request does not constitute any legal obligation, either on your or Peter J Pyburn's behalf.
  It is simply a request to get some medical aid options.
• All information provided will be strictly confidential at all times and will be freely transmitted to the email address provided.
  Peter J Pyburn will not be responsible should the information be incorrectly transmitted or not reach the correct recipient.
• Your email address will never be given to any other person or organisation.
  (I would never be in business if this happened!)

I confirm that I have read and understood the notes above. Yes

pyburn@peterpyburn.co.za