Wisdom Prestige Shoprite Dental Application

Wisdom Prestige Shoprite Dental Application
PRINCIPLE INSURED DETAILS

Note: please use the document upload feature at the end of the application form to upload a certified copy of your ID document, which is required in order to process your application.
Title
Name

First NameSurname
Gender
Date of birth

DayMonthYear
Date
Postal Address

Street Address

Street Address Line 2

CityState / Province

Postal Code
Phone Number Home

Area CodePhone Number
Phone Number Work

Area CodePhone Number
Fax Number

Area CodePhone Number
Cell number
E mail
example@example.com
Staff Number
Commencement Date

DayMonthYear
Date
DEPENDANTS DETAILS

Note: for each dependent, we require certified copies of ID documents or birth certificates, or appointment of legal guardianship or adoption.

CLAIMS PAYMENTS
Account Holder Name
Bank

Other
Account Number
Branch Name:
Branch Code:
Account Type
DECLARATON BY APPLICANT
I, the undersigned, hereby declare that:

1. All information supplied on this form, whether in my handwriting or not, is true and complete and will form the basis of this policy.

2. I understand that this is a dental insurance policy with stated benefits in terms of the Short Term Insurance Act 53 of 1998, and does not constitute a Medical Scheme product.

3. I understand that I may cancel this policy within 30 days with no loss.

4. I understand that my personal information will be shared with Guardrisk Insurance Company Ltd, the FSCA (Financial Services Conduct Authority) and their authorized representatives.
Signature
Date

DayMonthYear
Date
Please upload all supporting documentation, in order to process your application.

Browse Files
Principle Insured: certified copy of ID. For each dependent: certified copy of ID OR birth certificate OR appointment of legal guardianship / adoption Cancelof
POLICY PREMIUM DETAILS

Applicable from 1 January 2020 to 31 December 2020
Denis Insurance Administrators (Pty) Ltd Reg No 2008/006234/07 is an authorized Financial Services Provider FSP Number: 36026
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