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Policyholder Details
Name*
Prefix First Last
Policy Number*
ID Number / Passport*
Date of Birth*
MM slash DD slash YYYY
Email*
Home Phone Number
Work Phone Number
Cellphone Number*
Residential Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Admission Date
MM slash DD slash YYYY
Discharge Date
MM slash DD slash YYYY

Declaration by Applicant
I, the undersigned, hereby declare:
1. 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.
2. 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. I hereby waive any right to privacy of any insurance information provided by me or on my behalf, in respect of any insurance policy or claims I lodge. I also consent to this information being disclosed to any other insurance company and/or verified against other legitimate source or a database.
3. 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.
4. As part of the claims validation process, the services of a contracted third party is used in order to authenticate medical scheme membership, plan option type, relevant beneficiaries and agreed medical scheme option tariffs amongst other relevant information to validate the claim.
5. Sirago reserves the right to call for additional information of a clinical nature. In the event that Sirago requests a PMA (Post Medical Assessment) from my doctor as part of the claims assessing and authentication process.
6. I authorise Sirago Underwriting Managers to negotiate with service providers on my behalf for my medical claims and or bill and pay the provider directly.
7. In the event of a bereavement related claim the Insurer will pay the benefit into the principal or nominated beneficiaries account. The beneficiary must be noted on the policy prior to any loss. The insurer will require the full name, surname and ID to note the beneficiary. At the time of a claim the insurer will require the beneficiary’s ID and proof of bank. Should there be no beneficiary noted on the policy prior to the loss or should the insurer be unable to confirm the identity of the beneficiary, payment will always be made into the principal policyholder's account.
Name
First Last
ID Number / Passport
Signature
PLEASE NOTE:
Sirago Underwriting Managers (Pty) Ltd must be notified within 90 days of any occurance which may give rise to a claim. Claims will NOT be considered for assessment without the following documentation:
- A fully completed, signed claim form.
- Clear copies of all account statements.
- Medical Scheme statement showing all amounts paid by your Scheme.
- Proof of payment for amounts paid by the insured.
- Hospital account / Medical Scheme statement indicating co-payments imposed by the Medical Scheme.
- Cancer treatment plan if applicable.
All documents must be submitted within 90 days of payments by the Medical Scheme to qualify for payment. All policy terms apply to each claim submitted.
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Sirago Underwriting Managers (Pty) Ltd is an Authorised Financial Services Provider (FSP:4710). Underwriting Agency for GENRIC Insurance Company Limited (FSP:43638).
GENRIC is an Authorised Financial Services Provider and Registered Short-term Insurer.

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