Submit a membership enquiry | Cape Medical Plan

Home > Membership enquiry

Are you enquiring on behalf of your company?

Group Membership enquiry

Contact details

Name of company*

Contact person*

Landline number

Cellphone number

Email address

How would you prefer us to contact you?*
Select all that apply

Landline
Cellphone
Email

Company location

Street address*

Town*

Province*

Membership details

Number of members intending to join*

Claims ratio
This can be obtained from your current medical aid.

Referral details

Where did you hear about Cape Medical Plan?*

Private Membership enquiry

Contact details

Your full name*

Landline number

Cellphone number

Email address

How would you prefer us to contact you?*
Select all that apply

Landline
Cellphone
Email

Your location

Street address*

Town*

Province*

Current medical aid

If you currently belong to a medical aid, please provide the name

Why are you considering leaving?
Select all that apply

High costs
Poor service
Inadequate benefits
Other

If you selected "Other", please tell us your reasons

Details of prospective members

Please add as many dependants as necessary by clicking on "Add dependant" at the bottom of this section.
Main member

Full name*

Age*

Has this member been hospitalised in the last 12 months?*

Yes No

If yes, please provide details

Has this member been diagnosed with any chronic conditions?*

Yes No

If yes, please provide details

[Add dependant] [Remove a dependant]

Employment details

Employer name*

Telephone number*

Does your employer subsidise medical aid subscriptions?*

Yes No

May we contact your employer to find out whether any of your colleagues might be interested in Cape Medical Plan?

Yes No

If yes, who would be the best person to speak to?

Referral details

Where did you hear about Cape Medical Plan?*

Thinking of joining CMP? Get started by submitting a membership enquiry.