Comparative Quote Comparative Quote Step 1 of 4 25% Title* DrProfRevMrMrsMiss Name and Surname* First Last ID Number* Name of person submitting details* First Last Contact number* Alternative contact number / Daytime number* Best time to be contacted ie. 8am – 10am or 15:00pm – 17:00pm* Employer Name* Contact Number of Employer Are you receiving a medical aid subsidy?* YesNo Email* Province* Eastern CapeFree-StateGautengKwazulu-NatalLimpopoMpumalangaNorthern CapeNorth-WestWestern Cape City or Town* My Medical needs would be the following…….* Private Hospitalisation GP’s & Specialists Chronic Medicine Conservative Dentistry Advanced Dentistry Optometry Are u willing to make use of a network hospital to reduce your monthly contribution?* Yes i am willing to use a Network Hospital do Reduce my monthly PremiumNo, I want to make use of any Hospital Adult (s)* 12345678910 Child (ren)* 012345678910 Specify age of main member* Specify ages of additional adult dependants to be covered Specify ages of child dependants to be covered Are you currently pregnant?* YesNo Please indicate if any of the potential applicants is currently pregnant. Full time student* YesNo Are you currently on a medical scheme?* YesNo If yes, how many years in total on medical schemes? ie. 15 years Current Medical Scheme Name* Current Scheme Option* Why do you need a Quote? ** I can no longer remain on my current scheme due to employment policyI am Shopping AroundI want better benefitsI cant afford my current premium Do you suffer from any Chronic illnesses? ** YesNo If yes, please name chronic conditions? Please state the chronic conditions for which you receive medication. Gross monthly income of main member* No IncomeR1 to R3000pmR3001 to R6000pmR6001 to R10000pmR10001 to R15000pmR15001 to R20000pmMore than R20000pm Gross monthly income of spouse* No IncomeR1 to R3000pmR3001 to R6000pmR6001 to R10000pmR10001 to R15000pmR15001 to R20000pmMore than R20000pm I am currently paying the following amount on Medical contributions No ContributionR501 – R999pmR1000 – R1499pmR1500 – R1999pmR2000 – R2499pmR2500 – R2999pmR3000 – R3499pmR3500 – R3999pmR4000 – R4499pmR4500 – R5000pmR5001 + pm I am Willing to Spend the following amount on Medical contributions R501 – R999pmR1000 – R1499pmR1500 – R1999pmR2000 – R2499pmR2500 – R2999pmR3000 – R3499pmR3500 – R3999pmR4000 – R4499pmR4500 – R5000pmR5001 + pmI cant afford it but still need a quote Would you like to be contacted about other products?* YesNo If yes, choose the products Life Cover Disability Cove Severe Illness Cover Savings Retirement Planning Funeral Plans Car & Home Insurance Additional Info This iframe contains the logic required to handle AJAX powered Gravity Forms. .