Gap Cover Application

 

Steps to follow to apply for Stratum Gap Cover direct and pay R 0 brokers fee:

Select the Gap Cover option that will work the best for your unique circumstances. Complete and submit the electronic Gap Cover application on this webpage. An experienced financial advisor will prepare and send you necessary documents to approve with your signature. Send the signed documents with a copy of your ID and proof of membership of your medical scheme back as instructed, and your Gap Cover policy will be finalised as instructed.

Complete the form to apply for your Gap Cover:

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Gap Cover option application for:
Additional option applying for (if applicable)
Number of additional adult dependents
     
  Total premium per month
 
 
Inception Date (dd/mm/yyyy)  
     
MEDICAL SCHEME DETAILS    
     
Medical Scheme Name  
Medical Scheme Option  
Medical Scheme Nr.  
 
PRINCIPAL INSURED DETAILS
 
Title  
Full Name  
Surname  
ID Number  
Marital Status  
Preferred Language  
 
CONTACT DETAILS
 
Physical Address  
   
   
 
Postal Code
 
Postal Address  
   
   
 
Postal Code
 
Email Address  

Telephone - Cell

 
Telephone - Home  
Telephone - Work  
 
DEPENDANT DETAILS (As per Medical Scheme membership card )
 
 
Name Surname ID Number Gender Relationship
 
GENERAL PRACTIONER DETAILS  
   
Full Name
Surname
Telephone
Email Address
   
DEBIT ORDER DETAILS  
   
Monthly Payment Date
Account Holder
Bank
Account Number
Branch Code
Account Type
   
 
GENERAL
 
Is this application for the Comprehensive, Elite or G Force options?
   
BENEFICIARY NOMINATION FOR ACCIDENTAL DEATH BENEFIT  
 
(Accidental Death Benefit is only applicable to the Comprehensive, Elite & G Force options)
 
         
Name Surname ID Number Relationship Percentage
 
 
 
Apply | Application for Gap Cover

Gap Cover

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