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BONITAS MEDICAL AID QUOTE
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ONLY HOSPITAL COVER?YES or NO I WANT DOCTOR, DENTIST, CHEMIST, GLASSES AS WELL

NAME

EMAIL

TEL

CITY

HOW MANY ADULTS

YOUR AGE

PARTNER'S AGE

HOW MANY CHILDREN

YOUR CURRENT MEDICAL AID AND PLAN

TOTAL YEARS IN YOUR LIFE YOU HAVE BEEN A MEDICAL AID MEMBER

HOW MUCH CAN YOU AFFORD EACH MONTH

ANY CHRONIC CONDITIONS

WHAT DO YOU WANT FROM A MEDICAL AID

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I confirm that I have read and understood the notes above.Yes

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