Are you enquiring on behalf of your company?Yes
No

Company name:
Contact Person:
Telephone Number:
Cell Number:
Email Address:
Address:
Town:
Province:
Number of members wanting to join:
Claims Ratio:(this information can be obtained from your current medical aid)
Where did you hear about Cape Medical Plan?

First Name:
Surname:
Age:

Do you have any dependants?

Yes No

Family members' names and ages

Depdendant 1		Age
Depdendant 2		Age
Depdendant 3		Age
Depdendant 4		Age

Main Member:

Dependant 1:
Dependant 2:
Dependant 3:
Dependant 4:

Main Member:

Dependant 1:
Dependant 2:
Dependant 3:
Dependant 4:

Do you currently belong to a medical aid? Please supply name:
Why have you considered leaving?	--Select-- Cost Service Benefits Other
Other Reasons
Telephone Number:
Cell Number:
Email Address:
Address:
Town:
Province:
Does your company subsidise meical aid subscriptions?
For reference purposes, please supply the name and telephone number of your company.	Company Name Telephone Number
Can we contact your employer regarding other people within the company that may be interested in Cape Medical Plan?	Yes No
Who can we speak to?
Where did you hear about Cape Medical Plan?