MEDSURE GLOBAL DIGITAL APPLICATION

Welcome to our Scripted/Automated Advice process. You are required to read and understand this brochure as well as Policy Wording which is part of this marketing pack. Terms, Conditions and waiting periods will apply where necessary - If at any point you are unsure or do not understand, please 'WhatsApp' R&P Wealth Management FSP#46192 on 066 122 1528 and an accredited/qualified advisor will assist you.

PRINCIPAL INSURED / POLICYHOLDER DETAILS

Policy Inception Date

ID Number.

Passport Number: (not applicable if SA ID Number is entered) *

Title

First Name

Last Name

Gender

Male

Female

Date Of Birth

Email address

Home Phone#

Work Phone#

Fax Phone#

Cell Phone#

Applicant Receives Post at their residential address

Yes, I receive post

Cover is limited to the Policyholder and maximum of 4 Dependants in total.

Dependants are:
Either an Adult or Child who is dependent upon the Policyholder for access to the benefits available within this policy.

Adult: A person over the age of 21 (twenty-one), except for a full-time student over the age of 21 (twenty-one) who is dependent on the Policyholder and approved by Us as eligible for membership of this policy.

Child: A Child is a person under the age of 21 (twenty-one), who is considered to be the Immediate Family of the Policyholder eligible for membership in terms of this policy. Cover as a Child can be extended to the age of 27 (twenty-seven) if they are full-time students. Documented proof of full-time studies is required annually.

Immediate Family: The Immediate Family is a defined group of relations, whether over or under the age of 21 (twenty-one) and determines which members of a Policyholder's family may join this policy.

The definition extends to those connected to the Policyholder in the following manner:

- - - - By birth, adoption, stepchildren or grandchildren or any other child who has been placed in the custody of the Policyholder and in respect of whom the Policyholder is liable for care and support.
      - Parents/stepparents, grandparents in respect of whom the Policyholder is liable for care and support.
      - Siblings, including half-siblings in respect of whom the Policyholder is liable for care and support.
      - A Spouse of a Policyholder as defined in this policy.
      - Any other relative, who at the Insurers discretion, qualifies for membership under this policy.

Spouse: A person who is a signifcant other, partner or non-marital partner of that the principal member:

- - In a marriage or customary union recognised in terms of the laws of the Republic; or
  - In a union recognised as a marriage in accordance with the tenets of any religion; or
  - In a same sex or heterosexual union which the Underwriter is satisﬁed is intended to be permanent.
option one is only selected

Please refer to the terms and conditions in Policy Wording.

DEBIT ORDER AUTHORITY (for direct paying Members. Not applicable if you are part of a Group/Company who pays on your behalf).

Debit order on Main Members account

Title

Account Holder First Name*

Last Name

ID Number *

Passport

Date Of Birth

Email address

Home Phone#

Work Phone#

Fax Phone#

Cell Phone#

Account Holder Receives Post at their residential address

Postal Address *

*

Province *

City *

Postal Code *

Residential Address *

*

Province *

City *

Postal Code *

DEBIT ORDER DETAILS

and request the aforesaid institution to debit my/our account with all debits drawn against it by GENRIC Insurance Company Limited (GENRIC). All such withdrawals from my/our bank account by GENRIC Insurance Company Limited (GENRIC) shall be treated as though they had been signed by me/us personally. I/We certify that the above bank details are correct. If these banking details have not been provided accurately, or if the details change at any time in the future and I/we fail to notify such changes or if payments are not made in accordance with the Debit Order Instruction, the responsibility of payment will rest with me/us. I acknowledge that any fees and charges levied by the bank on account of the debit order or any debit order payments which may be rejected for any reason whatsoever will be for my account. Premiums are payable on a monthly basis by debit order. If two or more debit orders are returned, GENRIC Insurance Company Limited (GENRIC) will not be held liable should the policy be automatically terminated, or should claims incurred during this period of suspension not be paid. I acknowledge that any fees and charges levied by the bank on account of the debit order or any debit order payments which may be rejected for any reason whatsoever will be for my account. *If the facility is in the name of a Company, Close Corporation, Trust or Association the full names of such entity and the capacity of the signatory must be reflected. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the very next ordinary business day.

Title

Name of account holder *

Last Name

Account Number *

Bank*

Account Type *

Debit order day *

I hereby instruct and authorise you to draw against my bank account the amount necessary for payment of my monthly premium due in respect of the above mentioned insurance, without prejudice to the rights of GENRIC Insurance Company Limited (GENRIC). I further authorise you to increase the amount in the terms of the policy from time to time and authorise my bank to effect payment. I/We hereby confirm acceptance of the below mentioned insurance policy, and authorise GENRIC Insurance Company Limited (GENRIC) to issue and deliver payment instructions to their Banker, to draw on my/our account at the under mentioned institution in any manner agreed on between GENRIC Insurance Company Limited (GENRIC) and such institution, the amount of the premium payable on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement and commencing on the first day of

(Month) *

I/We understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks. I also understand the details of each withdrawal will be printed on my Bank statement bearing a specific reference number which will reflect your policy number as confirmed in the policy documents.

This authority may be cancelled by me/us by giving GENRIC Insurance Company Limited (GENRIC) thirty-one days’ notice in writing, however I/we understand that I/we shall not be entitled to any refund of amounts which GENRIC Insurance Company Limited (GENRIC) as withdrawn while this authority was in force, if such amounts were legally owing to GENRIC Insurance Company Limited (GENRIC).

I/We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement this authority and Mandate cannot be assigned to any third party.

IMPORTANT INFORMATION
• Please make sure FULL details are given for questions answered YES.
• Any application submitted to GENRIC, may at the discretion of the Insurer, and in terms of the prevailing Policy Wording, be underwritten. This means that Waiting Periods may be applied. Additional Dependants added after the policy inception will be underwritten unless specific concession is granted by the Insurer. A policy can be re-underwritten, declared null and void or terminated if any misrepresentation or non-disclosure is made regarding any detail that is material to this insurance. Any incorrect information may affect the validity of this contract.
• The onus lies on the insured to make sure that premiums are paid on a monthly basis. Reference on bank statements read: {policynumber}
• In the event of a bereavement related claim the Insurer will pay the benefit into the policyholder or nominated beneficiaries account. The beneficiary must be noted on the policy prior to any loss. We will require the full name, surname and ID to note the beneficiary. At the time of a claim we will require the beneficiary’s ID and proof of bank. Should there be no beneficiary noted on the policy prior to the loss or should we be unable to confirm the identity of the beneficiary, payment will always be made into the policyholders account.

Declaration and informed Consent in terms of the Protection of Personal Information Act 4, of 2013 (POPIA)

We at GENRIC Insurance Company Limited (GENRIC) & MedSure Global respect your right to privacy. We need to collect and process some of your personal information in terms of various Privacy and Data Management laws and are bound by the terms and provisions of the Protection of Personal Information Act, regarding the acquisition, usage, retention, transmission and deletion of your personal information.

Your personal information collected is for the primary purpose of providing you with insurance cover and for all other activities and processes incidental to and relevant to this purpose. As this information forms the basis of our assessment and terms, we offer you, it must be correct, complete, and up to date.

We will always comply with all relevant regulations in dealing with your information and keep it secure and confidential at all times.

Your information shall be kept confidential, however, we shall disclose it to certain third parties as required and other insurers for the specific purpose of insurance and to reduce and prevent any form of fraudulent activity.

Should you decide to cancel this insurance contract you further consent to GENRIC & MedSure Global, in retaining the information in line with the legally permitted retention period, for statistical and reporting purposes only.
I hereby voluntarily consent to GENRIC & MedSure Global processing my Personal Information.
I understand the purposes for which my Personal Information is required and for which it will be used.
I give GENRIC & MedSure Global permission to process my Personal Information as provided above.
Our Privacy Notice and POPIA Policy provides the details of how we deal with the personal information of our clients, and it is available on our website at the following address: https://www.genric.co.za (GENRIC) & https://medsureglobal.com (MedSure Global).

MEDSURE GLOBAL DIGITAL APPLICATION

PRINCIPAL INSURED / POLICYHOLDER DETAILS

Policy Inception Date

ID Number.

Passport Number: (not applicable if SA ID Number is entered) *

Title

First Name

Last Name

Gender

Date Of Birth

Email address

Home Phone#

Work Phone#

Fax Phone#

Cell Phone#

Applicant Receives Post at their residential address

Postal Address *

*

Province *

City *

Postal Code *

Residential Address *

*

Province *

City *

Postal Code *

OPTION SELECTION

Select Plan Option

PolicyNo

Applicant*

Adult Dependant *

Child Dependant *

Applicant Premium (*Including Intermediary Fee)

R 160.00

Adult Dependant Premium

R 0.00

Child Dependant Premium

R 0.00

Premium per month

R 0.00

* Intermediary Fee

R 50.00

TOTAL PREMIUM PAYABLE

R 0.00

Agent Name:

Agent Code:

Sub Agent Name:

Sub Agent Code:

Terms and Conditions*

Signature Date:

Adult Dependant or 1st Child Dependant

Title

First name

Last name

Gender

ID Number: *

Passport Number: *

Date of birth

Relationship to applicant *

2nd Child Dependant

Title

First name

Last name

Gender

ID Number: *

Passport Number: *

Date of birth

Relationship to applicant *

Third Child Dependant

Title

First name

Last name

Gender

ID Number: *

Passport Number: *

Date of birth

Relationship to applicant *

Fourth Child Dependant

Title

First name