Premier Youth – Application Form

Youth Option Eligibility

The Youth Option applies when the main policyholder is under the age of 26 and no dependants over the age of 26 are included on the policy.

Premier Youth offers the same coverage as our Premier solution, but is aimed at members under the age of 26. It offers a vast range of benefits to cater for unforeseen medical expense shortfalls and provides comprehensive cancer benefits. Click here for more information on Premier.

Monthly premium for Premier Youth: R315 per month

If we can be of any assistance with your submission, please don’t hesitate to contact us on newbusiness@turnberry.co.za or 011 677 9891.

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Application type

Application type(Required)

I am a broker completing the application with and on behalf of the applicant?

I am completing the application myself

If completing via a broker, the application form will be sent to the broker's email address.

Broker details

Broker name(Required)

Broker code(Required)

Broker email address(Required)

Main principle details

Title and Name(Required)

Title First Last

Cellphone(Required)

Email(Required)

Home telephone

Work telephone

ID / Passport Number(Required)

Gender(Required)

Address(Required)

Address Line 1 Address Line 2 City Province Postal code

Medical aid details

Medical aid name

Medical aid plan

Medical aid number

In the event of the death of the Principal Insured person in respect of the Critical Illness Benefit or Personal Accident Benefit:

Beneficiary name

Beneficiary ID

Relationship

Medical expense shortfall details

The products offered in this application form are not a medical scheme and the cover is not equivalent to that of a medical scheme. These products are not a substitute for a medical scheme membership.

Commencement date(Required)

DD slash MM slash YYYY

Are you transferring your Policy from another provider?(Required)

If you are transferring your Policy from another provider please attach your existing policy(Required)

Max. file size: 256 MB.

Age

What is your age?(Required)

Waiting periods

PLEASE NOTE, a 3-month general waiting period applies to all benefits (except in the event of an accident, which occurred while on the Policy). In the event the commencement date of the Policy is the same as the commencement date of the Medical Scheme, no 3-month general waiting period will apply to Medical Expense Shortfall Cover (increasing the medical aid rate up to 600%). A 10-month waiting period on pregnancy/childbirth. A 12-month waiting period on/or investigations, treatment or surgery for: hysterectomy, hysteroscopies, endometriosis, ovarian cysts and fibroids (myomectomy), muscular-skeletal (except in the event of an accident, which occurred while on the Policy), tonsillectomy, myringotomy, grommets, adenoids, wisdom teeth, hernia, cataracts, gastroscopies, colonoscopies, nasal and sinus, cancer.

Bank details for deductions of monthly premium by debit order

Account holder's name(Required)

Name of bank(Required)

Account number(Required)

Branch code(Required)

Type of account(Required)

Cheque

Savings

Transmission

Date account to be debited(Required)

1st

7th

15th

25th

Please note, should the collection date selected fall on a weekend or public holiday, a debit will be processed against your account on the first working day following the weekend or public holiday. Please note that your debit order reference will be TMS HEALTH INS D followed by your debtor number. I hereby request and authorise Turnberry Management Services (Pty) Ltd to draw against my bank account with the abovementioned bank (or any bank/branch to which I may transfer my account) the amount necessary for payment of the premiums (as well as any renewal or adjustment premiums and Policy fees due) in respect of the aforementioned insurance benefits. All such withdrawals from my bank account by Turnberry shall be treated as though they had been signed by me personally. I agree to pay the bank charges in connection with this instruction and authorise Turnberry to increase the amount of each withdrawal so as to recover the costs thereof in accordance with the South African Clearing Bank’s tariff in force at the time. I understand that: 1) the withdrawals hereby authorised will be processed by computer, and 2) details of each withdrawal will be reflected on my bank statement or on the accompanying voucher, and 3) the obligation to ensure that my monthly payments are received remains with me despite the granting to Turnberry of this authority and 4) that this authority may be ceded or assigned to a third party, if this Policy is also ceded or assigned to the third party. This authority shall continue in full force and effect until cancelled, by me, giving 31 days’ written notice thereof sent to Turnberry by prepaid registered post. I understand that such cancellation may result in the cancellation of the Policy and it will not relieve me of the liability in respect of any unpaid balance owing to Turnberry. In addition, I shall not be entitled to any refund of any amount which Turnberry has withdrawn regarded as receipt thereof by my bank.

Signature(Required)

Declaration by the principal insured person

Consent(Required)

I agree to the following terms:

I have been informed of my rights in terms of the Policyholder Protection Rules to have the following information disclosed to me before entering into any insurance contract:
1)The Statutory Notice;
2) Intermediary’s accreditation and mandate confirmation;
3) Mandatory disclosures.

I hereby apply for the benefits stipulated in this document, subject to the terms and conditions of the Policy contract and I agree that this application and declaration shall be the basis of the contract between me and Lombard Insurance Company Limited (”Insurer”).

I hereby warrant that the answers and statements provided in the application form are true and correct in every particular and that I have withheld no information whatsoever, which is material to or is likely to affect the assessment of the risk under the proposed insurance. I undertake to advise Turnberry in writing if a change takes place in the health of the Insured person/persons between the date of signing the application and the date of acceptance of the risk or the date of commencement of the Policy whichever occurs last.

I understand that any inaccurate and untrue statements or failure to notify Turnberry of a change in health prior to the acceptance and/or commencement of the Policy may render my Policy null and void and all premiums paid will be forfeited to the Insurer. I acknowledge that no representation made to me by any agent or employee of the Insurer shall in any way bind the Insurer unless it is thereafter confirmed in writing by the Insurer.

I hereby irrevocably authorise a) the Insurer to obtain from any person any information the Insurer needs to which this application relates; b) the person concerned to give the Insurer the information it requests under the authorisation in (a); the Insurer to share with other insurers and the ASISA any information to assess risks or claims. Any information may, under this authorisation, be obtained or given at any time, even after death.

I agree that a photocopy or fax of this application form is as effective and valid as the original. If I have an email address for correspondence with Turnberry, I accept the risks of email correspondence and shall not hold Turnberry liable for any loss or damage arising through any unauthorised access to the email correspondence with or any interception of any communication between Turnberry and me.

I acknowledge that should any of my personal and/or banking details change it is my responsibility to ensure that Turnberry are notified of the changes.

I acknowledge that the premium is due monthly in advance on the first day of each calendar month (“due date”) and if not received by Turnberry by the 15th day of the following calendar month, then this Policy shall be deemed to have been cancelled at midnight on the due date. I acknowledge and accept that for the purposes of effectively administering my policy and dealing with all other matters related thereto, Turnberry Management Risk Solutions may process and share my and the persons I represent herein private information with Lombard Insurance Company Limited and any associated party, any third party service provider, and/or agent who will assist in the administration and performance of my policy.

Have you been advised of and exercised your free choice to take out insurance with the Insurer and intermediary of your choice?(Required)

Yes

I confirm that the product benefits have been explained to me(Required)

Yes

Is this Policy replacing a Policy of the same or similar type?(Required)

Yes

If “YES”, have the product benefits and restrictions been adequately compared and explained to you?(Required)

Yes

Signature(Required)