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
helpdesk@tic.co.za. 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:___________________________________
