Agility Gap & CoPay Employer Application

Agility Gap & CoPay Employer Application
Name of Group
Requested Date of Inception

DayMonthYear
Date
Option Selection (if you select more than one plan, just add additional plans as required)
Click HERE to download the Group Onboarding spreadsheet and enter your team’s details. Please upload the completed spreadsheet at the end of this form.
Employer Details
Employer Group Trading Name
Company Registration No.
Employer Contact Person
Telephone No.
Please enter a valid phone number.Format: (000) 000-0000.
Title/ Role Description
Email Address
example@example.com
Alternative Employer Contact Person
Alternative Email Address
example@example.com
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nature of Business
VAT No.
Group Eligibility Details
Will cover be available to all employees?
Can member correspondence be sent to group HR?

Details of the group (To be completed in all instances)

Rows	Amount
State the total number of employees actively employed by your company
State the total number of pensioners
State the total number of active employees eligible to be covered
State the total number of active employees that will participate
State the total number of pensioners eligible to be covered
State the number of branches

Existing Medical Scheme Details
Please provide details of your group’s medical scheme membership over the past 2 years.
Has your company ever been declined, loaded, or had exclusions applied by a medical scheme?
If yes, please provide details
Billing & Schedules
Billing Details
Benefit Options & Communication
Welcome Packs Delivery Method
May we communicate directly with the members?
Communication Type
Communication Type - Other
Group Communication: Contact Details
Payment Details
Payment Method
Banking Details
Authorised Signatory

Full NameSurnameDesignation
Intermediary / Broker Details
Full Name of Broker

First NameMiddle NameLast Name
Brokerage Details

Name of BrokerageAgility Gap & CoPay CodeEmail Address
Final Employer Declaration
Signed By (Name & Surname)
Designation
Signed At (Place)
Date of Signature

DayMonthYear
Date
Authorised Signatory(ies)
Authorised Signatory(ies)
Employee Data Upload
Important: Click HERE to download the Group Onboarding spreadsheet and enter your team’s details. Please upload the completed spreadsheet at the end of this form.
Upload Employee Data (Note: Upload the completed spreadsheet per the link above)

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Disclaimer

Agility Gap & CoPay is a division of Agility Insurance Administrators (Pty) Ltd, a registered Financial Services Provider (FSP 44024). Product are underwritten by GENRIC Insurance Company Limited (FSP 43638), an Authorised Financial Services Provider and licensed non-life Insurer.
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