Application and Amendment Form
IMPORTANT NOTE: Please complete and sign this form and return to your Broker who will submit to Kaelo on
your behalf. Kaelo will only accept applications received by a Broker. Applications received after the 15th of the
current month will only activate the first of the following month.
A Application Status:
New Application:
For new applications, please complete all sections of this form.
Amendments to an existing Policy:
Current Policy Number:
For all amendments / updates please complete the relevant section that you are amending as well as completing the Broker Details
Section and the Declaration Section.
B Application Details:
Cover Start Date:
C Policyholder Details:
Personal Details:
First Name:Yumna
Surname: Samuels
ID Number: 9902050224086 Date of Birth:
05/02/1999
Gender: Female Cellphone: 0628118560
Postal Address:
103 Laingsberg Road , Heideveld , Athlone , 7764
Employer Details:
Employer Name:
Branch Name:
Date of Employment: Employee Number:
D Dependant Details:
Select one of the following:
Addition of dependants on a new application
Addition of dependants to an existing Policy
Removing dependants
Updating / amending dependants details
Should you have more than three dependants, please complete a second form and submit the forms together.
Dependant Number: 1 2 3
Surname:
Full Name:
ID Number:
Cellphone:
Email:
Relationship:
Inception / Start Date:
This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme. This Policy is not a substitute for Medical Scheme membership.
Kaelo Risk (Pty) Ltd is an authorised financial services provider (FSP: 36931).
This product is underwritten by Centriq Insurance Company Limited (FSP 3417).
E Broker Details:
Name: Surname:
Broker House: Broker House Code:
FSP Number: Cellphone:
Email:
If applicable, the Broker Fee form must be read in conjunction with this application form.
F Additional Documents:
Please ensure that the following documents are submitted with your application or amendments.
• A clear copy of either the ID or Birth Certificate of all Insured Parties being registered.
G Declaration:
Yumna Samuels
I, _________________________________________________________________________________________ (full name) hereby declare that this application form, whether in my
handwriting or not, is accurate and complete and forms the basis of the contract of insurance between the Underwriter and myself.
I hereby apply for the insurance product/s and agree to abide by its Policy rules and/or those of its Underwriter and any amendments
thereto which may be made from time to time. I confirm that all the information provided herein is complete and true and that I have not
concealed any relevant or pertinent information that may affect the evaluation of risk considered under this Policy of cover.
I understand that the provision of any false, misleading or missing information could result in my application being rejected or my Policy
being cancelled or claims being rejected. Should this occur, I agree to refund all Benefit payments that I have received in relation to this
Policy of insurance.
Premiums due to Centriq are payable monthly. Premiums that are in arrears will result in my Policy being suspended or possibly
terminated. In the event that any Policy Benefit becomes payable subsequent to or as a result of my death, I hereby provide an
irrevocable authority for such Benefits to be paid directly to my surviving spouse or failing such circumstance to the nominated guardians
or trustees responsible for the future care of my minor children or failing either of the preceding events to my estate. Where applicable, I
hereby authorise Centriq to draw against the above bank account all amounts due to Centriq in terms of this insurance cover. Should the
relevant Premiums be adjusted by the Underwriters, I hereby confirm that the adjusted amount may be drawn from the above account
subject to the notice period outline in the Policy document. This request is to remain in force unless cancelled by one month's written
notice. Where my employer deducts the Premium from my salary. I hereby provide authority for my Employer to deduct such Premium and
pay this across to Centriq. I accept that any notice given to my employer is deemed to have been given to me.
This is not a Medical Scheme and the cover is not the same as that of a Medical Scheme. This Policy is not a substitute for Medical Scheme membership.
Kaelo Risk (Pty) Ltd is an authorised financial services provider (FSP: 36931).
This product is underwritten by Centriq Insurance Company Limited (FSP 3417).
