Name & Surname
SA ID Number
Phone Number
Email Address
Country of Permanent Residence
HPCSA Registration Number
Address
Professional Credentials
Please state your relevant qualifications and experience
Qualification(s)
Institution
Year achieved
Remove
Insured's Professional Activities
Please select your current title for which you require cover
Community Medical Officer
Medical Officer Grade 1
Medical Officer Grade 2
Medical Officer Grade 3
Intern
Registrar
Specialist
If you have chosen to specialise, please indicate your specialty
State Hospital
Private Hospital
% Time spent in your professional capacity
Hours per week spent
Do you require additional cover for work/services rendered other than state?
Yes
No
I am authorised to sign this Proposal Form.
The above statements are correct, true and complete.
No information material to this Proposal Form has been withheld.
I have read the important facts which you have put before me and I understand the advice given in relation to the duty of disclosure.
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