Medical Insurance from Selfmed

Are your researching and comparing medical aids? Complete this form and let our expert consultants advise you on the most suitable plans to cover your family's healthcare needs. Find out more about our medical aid plans or read our medical aid industry news

PERSONAL DETAILS

First Name:

* Required

Surname:

* Required

ID Number:

Telephone No.:

Fax No.:

Cell No.:

* Required

Email:

* Required

Postal Address:

Postal Code:

Province:

Employer:

Employment Sector:

Private State

Subsidy:

Yes No

If Yes:

MEDICAL SCHEME DETAILS

Name of Medical Scheme:

Which Option:

Monthly Contribution:

Are you Interested in a
specific Selfmed Option:

HOW MANY PEOPLE IN FAMILY

No. of Members:

Spouse:

Dependants over 21:

Children under 21:

CHRONIC MEDICINE USERS

Number of chronic users in Family:

Cost of chronic medicine
per Month:

Chronic Conditions:

DAY-TO-DAY BENEFITS (EG. DOCTORS AND ACUTE MEDICINE)

Required:

Yes No

Monthly Amount Required:

Previously on a Medical Scheme?:

If YES, years in total:

Name of scheme(s):

Further Requests:

Selfmed Medical Insurance Quote