Corporate Cover Application Form

MEDICAL ENROLMENT FORM.
Staff Details:
DEPENDANTS DETAILS Please complete the following for your dependants. If there are more than 5 dependants then please complete a separate form for the others:
DEPENDANT 1
DEPENDANT 2
DEPENDANT 3
DEPENDANT 4
DEPENDANT 5
DEPENDANT 6
MEDICAL DECLARATION (for self and Dependants) Please indicate by ticking if you or any members of your immediate family have suffered /are suffering from any of the following:
SERVICE AGREEMENT Case Medcare hereby agrees to provide and the Client hereby agrees to utilize the medical services of the Hospital at its above address. Case Medcare hereby warrants that it will diligently provide such services to the Client to the best of its ability using accepted scientific methods as and when required to do so by the Client. The Client hereby undertakes to pay for any additional services rendered to him which exceed the financial limits of the contractual terms. The Client hereby understands that membership fees are not redeemable 60 days after inception of cover. If termination, for whatever reason occurs within 60 days, membership fees are refundable, less the cost of treatment received by the Client during that period plus an administrative charge of 5% of the membership fee.

**This plan does not cover Sicklers (ie sicklecells disease, cancer, heart disease etc

Case Medcare provides individual, family and group (corporate) health insurance plans. These plans are Client centred, Affordable, Safe and Effective in reducing the out of pocket payment burden that leads many households to financial catastrophe.