I,the undersigned ,hereby declare :
1. That to the best of my knowldege and beleif the information provided in connection with this application whether in my own handwriting or not,is true and I ahve 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 ommited in this proposal form may lead to Sirago Underwriting Managers (Pty)Ltd not meeting claims,should the ommited 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 or premiums.
3. That I understand that this is an accident and Healthy policy with stated benefits in terms of theShort-term Insurance Act 53 of 1998 and not a Medical Schemes product
4. The sharing of claims information and underwriting information by Insurers is essential to enable the insurer is essenntials to enable the insurance industry to underwrite policies,assess risks fairly,reduce the incidence of fraudelent claims and protect the public in terms of limiting excessive premium increases.You hereby waive any right to privacy of any insurance information provided by you or on your behalf ,in respect of any insurance policy or claims you lodge.You also consent to this informaion being disclosed to any other insurance company and/or verified against other legitimate source or a database.
5. I specifically consent to Sirago Underwriting Managers(Pty)Ltd contacting my current Medical Scheme and or medical practioner to verify any medical details as provided in my application form.I further consent to such information being disclosed to Sirago Underwriting Managers (Pty)Ltd for purpose of verifying the disclosure as provided on my application form