Profmed Medical Scheme

		(011) 644 4200
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INFORMATION

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Complete the form below for a free, no obligation quote on the Profmed medical scheme (for university graduates only):

Title
First Name
Surname
ID Number
Tel no & code
Fax no & code
Cellular Number
E-mail
Street Address


Postal Code
Province
University Degree
Occupation
Salary p/m
Employment sector
Subsidy	Yes No	If 'YES', %
DETAILS OF CURRENT SCHEME
Medical Scheme
Which option?
Monthly premium
HOW MANY PEOPLE IN YOUR FAMILY
Member
Spouse
Dependants over age 21
No. of children (under 21)
CHRONIC USERS
No. of chronic users
Cost per month
Chronic conditions	Specify conditions
DAY-TO-DAY EXPENSES (e.g. DR's & MEDICINES)
Required?	Yes No
Monthly Amount
IF YOU AND/OR YOUR SPOUSE ARE OLDER THAN 34 YEARS OF AGE, PLEASE COMPLETE THE FOLLOWING
On a Medical Scheme before 01/04/2001 to date?	Yes No
Have you previously belonged to a Medical Scheme as an adult?	Yes No
If 'YES', Years in total
Name of Scheme(s)
Comments

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