Application Form

Gap Cover Membership Application Form

1Your Details

2Application Status

3Your Medical Scheme

4Your Dependants

5Bank Details & Previous Cover

6Questionnaire

7Declaration

Name

This field is for validation purposes and should be left unchanged.

This field is hidden when viewing the form

part_type

Used in back end for existing employers. When compulsory many of the fields are already known or not required. known fields will be dynamically populated.

This application form can be used to join your employer’s group scheme or to join in your private capacity.

Please note that you will need the following in order to complete this application form:

If applicable, your spouse’s ID number (or passport number)
If applicable, the birthdates of your children
The benefit option of your medical scheme that you are covered on
Name of the advisor who advised you on this policy application

Title(Required)

Name and Surname(Required)

Email(Required)

Enter Email Confirm Email

Cellphone number(Required)

Alternative telephone number

Form of identification(Required)

Namibian Identity Number

Passport Number

ID No(Required)

Passport No.(Required)

Occupation(Required)

Identification Document(Required)

Accepted file types: pdf, jpg, png, gif, Max. file size: 3 MB.

Please upload a copy of your ID or Passport.

Date of Birth(Required)

Age(Required)

Please enter a number less than or equal to 65.

Please note:

Premium Basis: Premium calculations are determined solely on the age of the main member at the time of joining.
Main Member Requirement: The individual registered as the main member on the gap cover policy must also be the main member on the underlying medical scheme.
Maximum Entry Age: The maximum entry age for any person joining gap cover is 65 years. If a spouse or dependent is older than 65 at the time of application, they are not eligible for cover.

Gender(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code Country

Please note that you can only add your spouse and/or children to your policy, and you must all be registered on the same medical scheme membership.

You or your spouse (if relevant) can be the applicant for this policy. As long as all the insured persons on this policy are registered on the same medical scheme membership.

Description of Dependant Types :
Spouse – this includes a common-law spouse or life partner
Children - includes stepchildren
Notes on Child Dependants

A maximum of two children will be charged on your policy until they are 24 years old.
Adult premiums will apply to all children on your policy as from age 24 onwards.
There is no maximum age for children to stay on your policy, as long as they are registered on the same medical scheme membership as you are.
Once they resign from your medical scheme membership, then they would need to apply for their own Hollard Gap policy.

Other Dependants – dependant types covered on your medical scheme that are not your spouse and/or children (eg parents) will need to apply for their own Hollard Gap policy

Medical Scheme(Required)

Membership Number

Commencement date of medical scheme membership(Required)

Benefit Option(Required)

The correct premiums and policy cover are determined by your benefit option – it is very important that you select the correct benefit option above.

Medical Scheme Certificate(Required)

Drop files here or

Max. file size: 3 MB, Max. files: 10.

Please upload a copy of your medical scheme certificate.

Please indicate what dependants are to be added to this policy

Spouse

Children

How many children are to be added to cover?(Required)

Confirmation(Required)

I confirm that these dependants and myself are all registered on the medical scheme membership provided above.

Details of Spouse

Title(Required)

Name(Required)

First Name Surname

Form of identification(Required)

Namibian Identification Number

Passport Number

ID No(Required)

Passport No(Required)

Date of Birth(Required)

Gender(Required)

Would you like us to copy your spouse on all Hollard Gap e-mail and sms communications sent to you?(Required)

Yes

Your spouse's cellphone number(Required)

Your spouse's email address(Required)

Details of your Children

Child's Name(Required)

First Name Surname

Child's Date of Birth(Required)

Child's Gender(Required)

2nd Child's Name(Required)

First Name Surname

2nd Child's Date of Birth(Required)

2nd Child's Gender(Required)

3rd Child's Name(Required)

First Name Surname

3rd Child's Date of Birth(Required)

3rd Child's Gender(Required)

4th Child's Name(Required)

First Name Surname

4th Child's Date of Birth(Required)

4th Child's Gender(Required)

5th Child's Name(Required)

First Name Surname

5th Child's Date of Birth(Required)

5th Child's Gender(Required)

6th Child's Name(Required)

First Name Surname

6th Child's Date of Birth(Required)

6th Child's Gender(Required)

Bank Details

Please confirm your banking details below for the monthly debit order deduction – deductions are made in advance on the 1st day of each month:

Bank Name(Required)

Account Holder Name(Required)

Account Type(Required)

Account Number(Required)

Branch Code(Required)

Source of Funds(Required)

Brief Description Of Source(Required)

Your monthly premium will be

Previous Gap Cover

Please note that the application of waiting periods on your policy will depend on you providing us with sufficient evidence of your previous cover.

Do you currently have gap cover with another provider?(Required)

Yes

Name of the other gap cover provider?(Required)

When did this policy commence?(Required)

Policy Number(Required)

When does or did the cover on this policy end?(Required)

Please read the ‘Disclosure of Relevant Information’ and ‘Consent to Access Medical Records and Personal Information’ sections below carefully and ensure that you understand them and your obligations in supplying information that is true, honest and complete.

As the main applicant, you are completing the questions below on behalf of your dependents and you confirm that you have the necessary knowledge and authority to fully do so. It remains your responsibility to answer all of these questions accurately and honestly.

Please answer all the questions below :

Question 1: In the past 12 months, have you or any dependant consulted with or received advice, treatment or diagnosis from any doctor or medical service provider, and/or undergone any form of x-ray or CT/MRI/PET scan?(Required)

Yes

Question 2: Are you aware of any reason - including pregnancy/childbirth - that you or any dependant may be admitted to a hospital or a day clinic within the next 12 months?(Required)

Yes

Question 3: Do you or any dependant currently: take any ongoing medication, and/or receive any other ongoing treatment for any medical condition?(Required)

Yes

Details for Question 1

Please provide the details below in relation to your answer to Question 1:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Date of Treatment / Consultation(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

Please provide any further details regarding the treatment, advice or diagnosis received(Required)

Does Question 1 also apply to another applicant?(Required)

2nd Set of Details for Question 1

Please provide the details below in relation to your answer to Question 1 for the second person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Date of Treatment / Consultation(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

Please provide any further details regarding the treatment, advice or diagnosis received(Required)

Does Question 1 also apply to another applicant?(Required)

3rd Set of Details for Question 1

Please provide the details below in relation to your answer to Question 1 for the third person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Date of Treatment / Consultation(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

Please provide any further details regarding the treatment, advice or diagnosis received(Required)

Does Question 1 also apply to another applicant?(Required)

4th Set of Details for Question 1

Please provide the details below in relation to your answer to Question 1 for the fourth person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Date of Treatment / Consultation(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Name of radiologist (if applicable)

Telephone number of radiologist (if applicable)

Please provide any further details regarding the treatment, advice or diagnosis received(Required)

Does Question 1 also apply to another applicant?(Required)

Our online application form can only facilitate a maximum of 4 applicants’ answers to a medical question. Please continue to complete this application and once we have received it, we will contact you in order to obtain the additional medical answers that you wish to provide for the 5th applicant on your policy. Please note that your policy application will not be activated until we have received this additional information.

Details for Question 2

Please provide the details below in relation to your answer to Question 2:

Which applicant does this relate to?(Required)

Please describe the diagnosis and/or condition(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

When is the admission expected?(Required)

What date is the admission booked for?(Required)

Please provide any further details regarding the expected treatment(Required)

Does Question 2 also apply to another applicant?(Required)

2nd Set of Details for Question 2

Please provide the details below in relation to your answer to Question 2 for the second person:

Which applicant does this relate to?(Required)

Please describe the diagnosis and/or condition(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

When is the admission expected?(Required)

What date is the admission booked for?(Required)

Please provide any further details regarding the expected treatment(Required)

Does Question 2 also apply to another applicant?(Required)

3rd Set of Details for Question 2

Please provide the details below in relation to your answer to Question 2 for the third person:

Which applicant does this relate to?(Required)

Please describe the diagnosis and/or condition(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

When is the admission expected?(Required)

What date is the admission booked for?(Required)

Please provide any further details regarding the expected treatment(Required)

Does Question 2 also apply to another applicant?(Required)

4th Set of Details for Question 2

Please provide the details below in relation to your answer to Question 2 for the fourth person:

Which applicant does this relate to?(Required)

Please describe the diagnosis and/or condition(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

When is the admission expected?(Required)

What date is the admission booked for?(Required)

Please provide any further details regarding the expected treatment(Required)

Does Question 2 also apply to another applicant?(Required)

Details for Question 3

Please provide the details below in relation to your answer to Question 3:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Date of your last consultation(Required)

Please provide further details regarding the above treatment(Required)

Does Question 3 also apply to another applicant?(Required)

2nd Set of Details for Question 3

Please provide the details below in relation to your answer to Question 3 for the second person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Date of your last consultation(Required)

Please provide further details regarding the above treatment(Required)

Does Question 3 also apply to another applicant?(Required)

3rd Set of Details for Question 3

Please provide the details below in relation to your answer to Question 3 for the third person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Date of your last consultation(Required)

Please provide further details regarding the above treatment(Required)

Does Question 3 also apply to another applicant?(Required)

4th Set of Details for Question 3

Please provide the details below in relation to your answer to Question 3 for the fourth person:

Which applicant does this relate to?(Required)

Please indicate type of treatment(Required)

Name of the attending medical provider(Required)

Telephone number of attending medical provider(Required)

Date of your last consultation(Required)

Please provide further details regarding the above treatment(Required)

Does Question 3 also apply to another applicant?(Required)

We’re almost done – thank you for your patience.

As part of the process of completing this application for insurance cover I hereby warrant, declare, confirm and acknowledge that:

I have read and understood the contents of this application form and agree to be bound by the terms and conditions of the application form, the policy document and policy schedule, which together, form the policy contract.
All the information provided in this application is true, honest and accurate and I have disclosed all material information to Hollard.
I have not withheld any information which may be material to the assessment of risk under this policy.
I declare that in the event that any medical advice, treatment or diagnosis that I or my dependants receive between the date of this application for cover and the date that the cover will incept, and such medical advice, treatment or diagnosis is either material to the assessment of risk under this policy or would have caused you to change your answer/s to the medical questions in this application, I will immediately inform Hollard of such medical treatment prior to the inception of this policy.
If I breach any of the warranties given, Hollard may reject any claim under this policy, cancel this policy or void this policy from inception and I will forfeit any premiums paid.
I, as the applicant, have the necessary authority and knowledge to complete the medical questions and provide the warranties provided in the medical questionnaire section above on behalf of myself and all of the dependants covered on this policy (if applicable).
I have read the brochure outlining the cover and fully understand the cover I am purchasing. I acknowledge that this policy is not a medical scheme and that the cover is not the same as that of a medical scheme.
Eligibility for cover under this policy requires that my dependents and I are active and paid-up beneficiaries of either my own or my spouse’s medical scheme.
Should I add or remove any dependent from medical scheme cover or should the benefit option of the medical scheme under which we are currently covered change, that I will immediately notify Hollard of such change.
My children or stepchildren (if applicable) covered under this policy will be charged child rates until they are 24 years old, after which they will be charged adult rates.
Should I wish to cancel this policy, I have 21 days within which to do so from the date of application and any premiums deducted or paid to Hollard will be repaid to me and no cover will be activated.
After 21 days, I can cancel this policy on 30 days' notice, subject to the terms and conditions of the policy and any conditions of participation that may be imposed upon me by my employer (if applicable).
I hereby authorise Hollard to process and store my own and my dependents’ personal information for the purpose of administering this policy.
I hereby give my financial adviser and the brokerage that employs them authority to deal with and complete this policy application form on my behalf as well as authority to deal with my policy once it is activated.
It is my responsibility to ensure that the monthly premiums are paid on the due date, regardless of whether these may be undertaken on my behalf by my employer or directly against my bank account via debit order. I acknowledge that if premiums are in arrears by 15 days or more, my policy may be suspended and if premiums are in arrears by more than 30 days or more my policy may be cancelled.

CONSENT TO ACCESS MEDICAL RECORDS AND PERSONAL INFORMATION

I hereby Hollard Life Assurance consent to obtain the medical records, medical claims or personal information for myself and my dependants for the purposes of underwriting the risk under this policy and/or to assess any claims against the policy. I agree that such consent extends to obtaining medical records, medical claims or personal information from my medical scheme and/or our medical service providers, including their sub-contractors who process or transfer the relevant medical records, medical claims and personal information between your medical scheme and your medical service providers. I agree that such consent also extends to obtaining medical records, medical claims or personal information data from medical data bureaus or credit bureaus who respectively act as aggregators of medical and credit information. I agree that this consent applies to the medical records, medical claims and personal information of myself and my dependants, and I declare that as the applicant for the cover under this policy I am duly authorised to provide such consent for myself and my dependants.

Gap Cover Membership Application Form

Bank Details

Previous Gap Cover

Details for Question 1

2nd Set of Details for Question 1

3rd Set of Details for Question 1

4th Set of Details for Question 1

Details for Question 2

2nd Set of Details for Question 2

3rd Set of Details for Question 2

4th Set of Details for Question 2

Details for Question 3

2nd Set of Details for Question 3

3rd Set of Details for Question 3

4th Set of Details for Question 3

Hollard Info

Broker Information

Customer Support