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Declaration by Applicant
I, the undersigned, hereby declare: 1. That to the best of my knowledge and belief the information provided in connection with this application whether in my
own handwriting or not, is true and I have not withheld any material facts which are known to me. (A material fact is likely to
influence the assessment of this application by Sirago Underwriting Managers (Pty) Ltd. If you are in any doubt as to whether a
fact is material or not, you should disclose it.) 2. That I understand that any relevant material fact omitted in this proposal form may lead to Sirago Underwriting Managers
(Pty) Ltd not meeting claims, should the omitted fact have been of such importance that the risk may not have been accepted
in the first instance, in terms of the policy. This may lead to the cancellation of this policy or rejection of claims without refund
of premiums. 3. That I understand that this is an Accident and Health policy with stated benefits in terms of the Short-term Insurance Act 53
of 1998 and not a Medical Scheme product. 4. The sharing of claims information and underwriting information by insurers is essential to enable the insurance industry to
underwrite policies, assess risks fairly, reduce the incidence of fraudulent claims and protect the public interest in terms of
limiting excessive premium increases. I hereby waive any right to privacy of any insurance information provided by me or on
my behalf, in respect of any insurance policy or claims I lodge. I also consent to this information being disclosed to any other
insurance company and/or verified against other legitimate source or a database. 5. By agreeing to the terms of this consent form, I expressly consent to the processing of my information for marketing
purposes and know and understand that by agreeing to same that I may on occasion, receive marketing materials in the form of
SMS and/or emails and the like from Pandemic Shield, my broker or Sirago Underwriting Managers.
Please select your option. You may only choose one option. If both options are selected, your application will be
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Debit Order Authority and Debit Authority Consent
I hereby instruct and authorize you to draw against my bank account the amount necessary for the payment of my monthly premium
due in respect of the above-mentioned insurance, without prejudice to the rights of GENRIC Insurance Company Limited. I further
authorize you to increase the amount in terms of the policy from time to time and authorize my bank to effect payment.
I/ We hereby confirm acceptance of the below mentioned insurance policy, and authorize Sirago Underwriting Managers (Pty) Ltd to
issue and deliver payment instructions to their Banker, to draw on my/our account at the undermentioned institution in any manner
agreed on between GENRIC Insurance Company Limited and such institution, the amount of the premium payable on condition that
the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement and commencing on
on the above- mentioned date and request the aforesaid institution to debit my/our account with all debits drawn against it by
GENRIC Insurance Company Limited.
All such withdrawals from my/ our bank account by GENRIC Insurance Company Limited shall be treated as though they had been
signed by me/us personally.
This authority may be canceled by me/us by giving Sirago Underwriting Managers (Pty) Ltd thirty days’ notice in writing, however I/
we understand that I/we shall not be entitled to any refund of amounts which GENRIC Insurance Company Limited has withdrawn
while this authority was in force if such amounts were legally owing to Sirago Underwriting Managers (Pty) Ltd.
I/ We certify that the above bank details are correct. If these banking details have not been provided accurately, or if the details
change at any time in the future and I/we fail to notify such changes, or if payments are not made in accordance with the Debit
Order Instruction, the responsibility of payment will rest with me/ us.
Premiums are payable on a monthly basis by debit order. If two or more debit orders are returned, Sirago Underwriting Managers
(Pty) Ltd will not be held liable should the policy be automatically terminated or should claim incurred during this period of suspension not be paid. I acknowledge that any fees and charges levied by the bank on account of the debit order or any order payments
which may be rejected for any reason whatsoever will be for my account.
If the facility is in the name of a Company, Close Corporation, Trust, or Association the full names of such entity and the capacity of
the signatory must be reflected. In the event that the payment day falls on a Sunday or a recognized South African public holiday,
the payment day will automatically be the very next ordinary business day. Payment instructions due in December may be debited
against my account on the above- mentioned date.
I/ We acknowledge that all payment instructions issued by you shall be treated by my/our above-mentioned Bank as if the instructions have been issued by me/us personally.
I/ We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that
third party, but in the absence of such assignment of the Agreement this Authority and Mandate cannot be assigned to any third
• Application forms could be underwritten. • The onus lies on the insured to make sure that premiums are paid on a monthly basis. Reference on bank statements read: MD_SIRAGO_MED • Effective from 1 July 2020. • In the event of a bereavement-related claim the insurer will pay the benefit into the principal or nominated beneficiaries account. The beneficiary
must be noted on the policy prior to any loss. We will require the full name, surname, and ID to note the beneficiary. At the time of a claim, we will
require the beneficiary’s ID and proof of the bank. Should there be no beneficiary noted on the policy prior to the loss, or should we be unable to confirm the identity of the beneficiary, payment will always be made into the principal policyholder’s account.
Statistics (Voluntary Completion)
We believe in protecting your privacy and will not share, rent or sell any personal information or any statistical data received to third parties outside of Sirago Underwriting Managers (Pty) Ltd except as described in this policy. I UNDERSTAND THAT this insurance will not commence before this proposal has been accepted by the insurer. I hereby request that the insurers provide insurance cover in terms of this Policy.
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