2017 SELFMED MEDICAL AID QUOTE
Plans, benefits and cost.

Please complete the blocks below and send to me. Get all the plan options, rates and information you need.
Need Selfmed Medical Aid.

DO YOU HAVE TO JOIN YOUR EMPLOYER'S MEDICAL AID?
YES or NO

ONLY HOSPITAL COVER?
YES or NO WANT DOCTOR, DENTIST, CHEMIST, GLASSES AS WELL

NAME

EMAIL

TELEPHONE

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?
AND YOUR PARTNER?

How much can you AFFORD EACH MONTH?

Any CHRONIC CONDITIONS?

WHAT DO YOU WANT FROM A MEDICAL AID?

Receive my informative letter on personal financial matters? Yes

Please note:

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

Exclusions and sub - limits apply, see brochures.

helpINVESTIGATE OTHER MEDICAL AIDS!

income protectionlife insurance quote peter pyburn brokerpeter pyburnemailpyburn@peterpyburn.co.za


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2017