CAMAF Member Option Guides & Info

Travel Insurance Form for CAMAF Members

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Application Form for CAMAF Scheme Members Dear CAMAF Member, Your CAMAF membership entitles you to 90 days travel insurance per journey. It will insure you and your dependants against emergency medical expenses you may incur whilst travelling abroad. Please note: An excess of R500 applies for out-patient treatment Pre-authorisation is required for expenses estimated to be over R10,000 To activate this benefit when travelling outside the borders of South Africa, please complete the form below and fax it through to +27 11 521 4413 or email it to Alternatively call TIC Help Desk on +27 11 521 4000 for assistance. A. Travellers' details and selection of cover No Title Initials Surname Medical Aid ID Number Relationship to Main Member Membership No 1. 2. 3. 4. 5. B. Other Details Telephone Number Facsimile Number E-mail Address Cell Phone Number Main destination House doctor Name/Number Country of residence Beneficiary Date of departure Date of return C. Please answer the following financial needs analyses Yes No 1. Do you understand that this is a short-term travel insurance policy and TIC is a licensed Financial Services Provider, FSP 3419? 2. Do you have a similar product? If yes, please stipulate: 3. Do you understand that there is no cost associated with this policy? 4. Do you understand the onus is on you to familiarise yourself with all the terms and conditions and exclusions detailed in the policy wording which you will be receiving? We draw your attention to the specific exclusions of pre-existing conditions, vascular, cardiovascular and cerebrovascular conditions if you are over the age of 69? 5. Do you request that we issue this policy for you? Signature:____________________________ Date:___________________________________

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