1. PRINCIPAL MEMBERS DETAILS (Maximum entry age = 60)
Surname   Full First Name(s)  
Date of Birth   ID Number  
Marital Status   Gender  
Postal Address   Postal Code  
Contact Number   Alternate Number  
Email Address   
2. SELECT YOUR PLAN (select one only)  
Product Select Cost per Month
BiologiCare R230 pm
Preferred Commencement Date      
3. DEPENDENT DETAILS (Immediate family members only - ie. spouse and own children) - Not Compulsory
First name(s) Surname Date of Birth / ID No Relationship
Pay to (Beneficiary) Medway Marketing (Pty) Ltd. Abbreviated Name Medway
Account Holder   Bank Name  
Branch / Branch Code   Bank Account No  
Type of Account  
Date of Debit Order  

I hereby authorise you to issue and deliver payment instructions to your banker for collection against my abovementioned account at my above-mentioned Bank (or any other Bank or branch to which I may transfer my account) on condition that the sum of such payment instructions will never exceed my obligations as agreed to in the Agreement and commencing on the date of debit order above and continuing until this Authority and Mandate is terminated by me by giving you notice in writing of not less than 30 days and sent electronically or by post to the address as indicated above. The individual payment instructions so authorised to be issued must be issued and delivered MONTHLY. In the event that the payment day falls on a Sunday, or a recognised South African public holiday, the payment day will automatically be the very next ordinary business day. I understand that the withdrawals hereby authorised will be processed through a computerised system provided by South African Banks. I also understand the details of each withdrawal will be printed on my Bank statement and will contain a number that enables me to identify the Agreement.

I acknowledge that all payment instructions issued by you shall be treated by my Bank as if the instructions have been issued by me personally.

I agree that although this Authority and Mandate may be cancelled by me, such cancellation will not cancel the Agreement. I shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you.

I acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement this Authority and Mandate cannot be assigned to any third party.

I furthermore agree to advise Medway of any changes to the above banking details.

I accept this declaration

  1. I hereby apply for the Medway policy(ies) as selected in Section 2 above, in accordance with the provisions and conditions as contained in the policy contract(s).
  2. I acknowledge that the level of cover and the rate at which contributions increase are not guaranteed and can be reviewed in the event of unforeseen circumstances, which materially affect the cost of providing cover.
  3. I understand and agree that, subject to the waiting periods, the Insurer will only be at risk once Medway accepts this application and the first contribution is received.
  4. Medway will send me the policy membership certificates and policy summaries pertaining to my product selection for me to examine. If the plan does not suit my needs, I must cancel it within 30 days of receipt, by providing written notification to Medway in order to qualify for a refund.
  5. I warrant that all information given in this Medway policy application form, whether in my handwriting or not, is true and complete. I understand that any misrepresentation or non-disclosure or provision of false information can lead to cancellation of these benefits, in which case, all monies paid to Medway will be forfeited.
  6. I undertake to keep Medway informed of changes to any banking details and my address to enable them to communicate with me.
  7. I have confirmed to my Intermediary (who has explained the possible disadvantages of replacing existing insurance policies) that I am not replacing an existing insurance policy with the Medway policy.
  8. I hereby confirm that I wish to receive the Policy Documents via Email.
  9. Have you, or any of your dependants sought any advice, been diagnosed with, or treated for any of the following conditions in the past 12 months: Tuberculosis, Heart Disease, HIV/Aids, Diabetes?
  10. Are you aware of any condition that may require medical treatment in the next 12 months for either yourself or any of your dependants?
            If yes, please give details:   
  11. Have you, or any of your dependants, ever been treated for Cancer, including Melanoma or Carcinoma?
            If yes, please give details:   
  12. Have you been a member of your current medical aid for more than three years?

I accept the declaration

6. INTERMEDIARY DETAILS & DECLARATION (only required if an Intermediary has been involved)
Name of FSP FSP Number
Agent / Representative
Code ID Number
Telephone (W) Cell Number

Click here to read the Statutory Disclosure