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It is important that you fill out the fields completely and accurately, as this information will be what is used in the event of an emergency. This information will be captured and stored in a secured servers and will be treated much like your banking account details.

If you have any questions, please guide them

Read the OVERVIEW and the BENEFITS first.

M E M B E R S H I P    A P P L I C A T I O N     F O R M

This form is vitally important - please complete it accurately, observing correct spelling. Please also check this document before submitting it for capturing.

This is a long form calling for your personal, vehicle and other insurance information. It would be a good idea to have this information on hand before filling out the required information. REMEMBER, this is the information that will be called for in the event of an emergency or crisis, so it needs to be complete and accurate, IT IS THE INFORMATION THAT COULD SAVE YOUR LIFE.

NOTE: ALL FIELDS marked [ * ] are required.

If you prefer not to give out "sensitive" information at this point, leave it out. YOU CAN INSERT AND UPDATE YOUR RECORDS WHEN YOU RECEIVE YOUR MEMBERSHIP DETAILS AND DO THIS ONLINE.

 

PRINCIPAL MEMBER DETAILS

First Name:
A value is required.
Surname:
 A value is required.*
Title:
ID Number:
Your 13 digit SA ID number is required..Invalid format. (13 digits)
Date of Birth:
(YY - MM - DD)
Postal Address:
Address 2:
Address 3:
Code:

SPAM CHECK - Are you human or a Spam bot?

Please enter the following to verify that you are human.
ENTER A RANDOM 6 DIGIT NUMBER HERE
 Enter any 6 DIGITS of your choosing.Invalid format. Real numbers only.
Physical Address:
Address 2:
Address 3:
Code:
Email:
 A correct value is required.Invalid email format.*
CONFIRM Email:
 *Retype your email address here.The values don't match.
Tel - Work:
A phone area code is required.   A valid day-time phone number is required.*
Tel - Home:
  
Fax:
   
Cell:
   
I/we herewith authorise MEDtag to contact myself via SMS or email for updates and / or promotions.

VEHICLE INSURANCE PARTICULARS
Vehicle Make:

(eg. Audi, BMW, Ford, Kia etc))
Model:
(eg. 1.8L, A3, Turbo or Focus Si, 1.6L Duratec )
Year:
Colour of Vehicle:

(eg. Blue, metallic green)
Insured by?
Policy Number:
Vehicle registration:

MEDICAL AID PARTICULARS

Medical Aid Company:
Your Medical Aid Plan:
Member number:
Member/s Covered:
Principal:
# of Children:
Spouse:
   
 
R 5 pm additional per dependent
 
Additional Dependent/s:

MEDICAL HISTORY

Have you or any of your dependents listed on this application form sought any advice, been diagnosed or are showing any symptoms of any serious illness that may have implications in the event of a life threatening situation? Allergies to medication and / or general allergies, major operations, injuries, HIV / AIDS, diabetes, asthma and / or cardiac conditions etc
Name of Person:
Details of condition, illness, allergy or injury

First Name
Surname

First Name
Surname

First Name
Surname

First Name
Surname

First Name
Surname

First Name
Surname

EMERGENCY CONTACT

 
FIRST PERSON TO CONTACT
First Name:
Surname:
Title:
Tel - Work:
  
Tel - Home:
  
Cell:
   
 
SECOND PERSON TO CONTACT
First Name:
Surname:
Title:
Tel - Work:
  
Tel - Home:
  
Cell:
   
Where did you hear about MEDtag?
What area
do you live in?
RE-ENTER YOUR RANDOM 6 DIGIT NUMBER HERE
 Retype the SAME RANDOM 6 DIGIT NUMBER YOU ENTERED ABOVE. This is required to continue and process this information.The values don't match.

Please make sure that all the fields are completed and spelling is correct (especially on your names) before submitting this information to MEDtag.
   

Thank you for completing this form. If you feel you would like to make contact with us directly, please do so here.

 
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© Copyright MEDtag 2008. All rights reserved.
MEET OUR PARTNERS
Yes, being a part of MEDtag means you get to our partners and their great products / services and we can talk a deal with them too ...
MEMBER BENEFITS
Check out what benefits our members receive when they join. Also, see what our partners have to offer.