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Personal Details (Main Member)

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Physical Address

Dependants to be Covered

Your Chosen Network Doctor

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Nominated beneficiaries

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Banking Details


I have read and understood the Terms and Conditions below.
I warrant that I have been provided with all the intermediary, insurer's and benefit details or any additional information that I may have requested. I warrant that all details and facts provided herein are accurate and properly disclosed, even if completed by the intermediary or a representative on my behalf. I understand that the hospital stated benefits plan offered are risk benefits only and that there are no surrender values. Failure to pay premiums will result in benefits lapsing. In the event of any query regarding this policy or any claim in terms of this policy, I consent to the disclosure of any relevant information to the intermediary or any Day1 Health (Pty) Ltd official for the purposes of resolving the query. In the event of no nominated beneficiary, I agree that necessary burial costs will be paid directly or to the person who paid for such costs. Any remaining benefit will, thereafter, be payable to the first claimant with reasonable title to claim any benefit.

I acknowledge that the Day1 Health (Pty) Ltd Insured Health Plan is not a Medical Aid.

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