Gapwise Quotation & Application Generate an instant, obligation free quotation below - and continue with the Gapwise application if you like what you see. 1 Obligation-free Quote2 Quote Result3 Apply for Gapwise4 Almost There...5 Time to Wrap It Up! Quote Applicant's DetailsConfirm/enter the details below, then select the Gapwise Plan you wish to have a quote for.First Name*Surname*Email Address* Cell Number* Your Gapwise PlanSelect your desired Gapwise plan from the dropdown list belowYour Gapwise Plan*Select Your Gapwise PlanPlus Gap Cover (Single)Plus Gap Cover (Family)Ultimate Gap Cover (Single)Ultimate Gap Cover (Family)Your Dependants*Select Your DependantsAdult Dependant OnlyAdult Dependant and Child Dependant(s)Child Dependant(s)Gapwise PremiumThat's All!To instantly see the monthly premium for your desired Gapwise plan, simply hit the "Quote Me!" button below: Your Quotation ResultYour Selected Gapwise PlanYour Monthly Premium R0.00 That was quick and easy, wasn't it? And you have to agree that it's a pretty low monthly payment for the awesome benefits you get. To get Gapwise cover for yourself and/or your dependent loved ones, simply click the "Apply for Gapwise" button below. Medical Sceme DetailsMembership Number*Medical Scheme Name*Part of a Group Scheme?YesNoGroup Name*Employer (if applicable) Principal Member's DetailsTitle*Mr.Ms.Dr.Prof.Full First Name*Full Middle NameSurname*Initials*Gender*Your GenderMaleFemaleDate of Birth* Date Format: DD slash MM slash YYYY Identification TypeIdentification TypeRSA ID DocumentRSA or Foreign PassportRSA ID Number*Passport Number*Physical Address* Street Address Address Continued City Province Postal Code Postal Address* Same as Physical Postal Address Address Continued City Province Postal Code Work PhoneIncl. city code, e.g. 011 123 456Cell Phone*E.g. 082 123 4567Home PhoneIncl. city code, e.g. 011 123 456Email Address* Where Did You Hear About Us?*Where Did You Hear About Us?GoogleFacebookTwitterEmailWord of MouthEmployerSMSOther DependantsSpouse/Adult Dependant's DetailsFirst NameMiddle NameSurnameID/Passport No.GenderSelect...MaleFemaleAdult DependantChildren's DetailsFirst NameMiddle NameSurnameID/Passport No.Gender Select...MaleFemale Child Dependants Health QuestionnairePlease answer the following 8 questions truthfully and as accurately as possible1. Have you been admitted to hospital in the last 4 months?*YesNoDetails for Question Number 1PersonFull DetailsDoctor (incl. Phone)Date Full names and accurate details including date(s) as far as possible. Use the + icons on the right to add more rows if necessary.2. Are you expecting a hospital admission or aware of any conditions or Illness that would require treatment in the next 12 months?*YesNoDetails for Question Number 2PersonFull DetailsDoctor (incl. Phone)Date Full names and accurate details including date(s) as far as possible. Use the + icons on the right to add more rows if necessary.3. Are you or any of your dependents currently pregnant?*YesNoDetails for Question Number 3PersonFull DetailsDoctor (incl. Phone)Date Full names and accurate details including date(s) as far as possible. Use the + icons on the right to add more rows if necessary.4. Have you taken or are currently taking chronic medication in the past 24 months?*YesNoDetails for Question Number 4PersonFull DetailsDoctor (incl. Phone)Date Full names and accurate details including date(s) as far as possible. Use the + icons on the right to add more rows if necessary.5. Have you been on gap cover before and/or have had a gap claim? If yes, who was the provider?*YesNoDetails for Question Number 5*PersonFull DetailsDoctor (incl. Phone)Date Full names and accurate details including date(s) as far as possible. Use the + icons on the right to add more rows if necessary.6. Have you or any of your dependants had a blood relative diagnosed with cancer?*YesNoDetails for Question Number 6*PersonFull DetailsDoctor (incl. Phone)Date Full names and accurate details including date(s) as far as possible. Use the + icons on the right to add more rows if necessary.7. Is there any additional information not specifically mentioned in this questionnaire that relates to your health state which may influence our decision on cover?*YesNoDetails for Question Number 7*PersonFull DetailsDoctor (incl. Phone)Date Full names and accurate details including date(s) as far as possible. Use the + icons on the right to add more rows if necessary.Important Information Please make sure FULL details are given for questions answered YES. Application forms could be underwritten and conditions may be excluded for longer than 12 months, or permanently. The onus lies on the insured to make sure that premiums are paid on a monthly basis. Effective from 1 January 2016. Payment & Inception DetailsPayment MethodPayment MethodAccount Holder*Bank Name and CodeBank Name and CodeAbsa Bank - 632005African Bank - 430000Capitec Bank - 470010First National Bank (SA) - 250655Investec Bank - 580105MTN Banking - 490991Meeg Bank - 471001Nedbank (SA) - 198765Postbank - 460005Standard Bank (SA) - 051001Albaraka Bank - 800000Bank Of Namibia - 980172Bidvest Bank - 462005Central Bank of Lesotho - 586611Citi Bank - 350005Finbond Mutual Bank - 589000First National Bank Lesotho - 280061First National Bank Namibia - 282672First National Bank Swaziland - 280164Grinrod Bank - 584000HSBC Bank - 587000JP Morgan Chase Bank - 432000Standard Bank of Namibia - 087373State Bank of India - 801000Ubank - 431010Unibank - 790005VBS Mutual Bank - 588000Account Number*When Should Your Plan Start?*When Should Your Plan Start?This MonthNext MonthThe Month ThereafterInception Date: Inception DateInception DateInception DateDebit DateSelect the Day of the Month...1st of the Month7th of the Month15th of the Month27th of the MonthTotal First Month DeductionMonthly Premium + R75 Activation FeeNormal Monthly PremiumThe usual monthly premium from the 2nd. month onward DeclarationPlease note that the Declaration below must be read and accepted along with the stipulations of the Policy Document. Please DOWNLOAD that version of the policy document which is applicable to the Plan you are applying for, and familiarise yourself with the contents thereof.Declaration by Applicant*I, the Principal Applicant, hereby declare: That to the best of my knowledge and belief the information provided in connection with this application whether in my own handwriting or not, is true and I have not withheld any material facts which are known to me (a material fact is likely to influence the assessment of this application by Sirago Underwriting Managers (Pty) Ltd. If you are in any doubt as to whether a fact is material or not, you should disclose it.) That I understand that any relevant material fact omitted in this proposal form may lead to Sirago Underwriting Managers (Pty) Ltd not meeting claims, should the omitted fact have been of such importance that the risk may not have been accepted in the first instance, in terms of the policy. This may lead to the cancellation of this policy or rejection of claims without refund of premiums. That I understand that this is an Accident and Health policy with stated benefits in terms of the Short-term Insurance Act 53 of 1998 and not a Medical Scheme product. The sharing of claims information and underwriting information by Insurers is essential to enable the insurance industry to underwrite policies, assess risks fairly, reduce the incidence of fraudulent claims and protect the public interest in terms of limiting excessive premium increases. You hereby waive any right to privacy of any insurance information provided by you or on your behalf, in respect of any insurance policy or claims you lodge. You also consent to this information being disclosed to any other insurance company and/or verified against other legitimate source or a database. I specifically consent to Sirago Underwriting Managers (Pty) Ltd contacting my current Medical Scheme and/or medical practitioner to verify any medical details as provided in my application form. I further consent to such information being disclosed to Sirago Underwriting Managers (Pty) Ltd for purpose of verifying the disclose as provided on my application form. That I will advise Sirago Underwriting Managers (Pty) Ltd of any changes to my health state between the point of application and actual inception of my policy. I hereby also 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 My-Fin Financial Services. 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 Agree to the Declaration The "agree" checkbox will be activated once you have read the declaration (scrolled to the bottom)Affordability* Yes I hereby declare that I can afford to pay the said premium monthly, and that I am not over-committing myself financially. MiscellaneousDo You Have a Promotional Code?NoYesEnter Promotional CodeAre You Married In Community of Property?NoYesSpouse's Agreement* My Spouse Agrees to the Purchase of this Policy Application Submitted by Intermediary?NoYesIntermediary*Intermediary Code*Email*Phone*Cell Phone*NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.