Name & Surname
SA ID Number
Mobile Number
Work Number
Country of Permanent Residence
Email Address
Address
HPCSA Registration Number
Professional Credentials
Please state your relevant qualifications and experience
Insured's Professional Activities
Please select your current title for which you require cover
Community Medical Officer
Medical Officer Grade 1
Medical Officer Grade 2
Medical Officer Grade 3
Intern
Registrar
Specialist
If you have chosen to specialise, please indicate your specialty
Please indicate the % time spent in your professional capacity in:
State Hospitals
Private Practice
How many hours a week do you spend in:
State Hospitals
Private Practice
Do you require additional cover for work/services rendered other than state?
Yes
No
I/We the undersigned duly authorised person(s) declare that:
I am/we are authorised by each of the Insureds to sign this Proposal Form.
The above statements are correct, true and complete.
No information material to this Proposal Form has been withheld.
I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure.
I agree to the
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