SafariMED Inbound Travel Cover
Application Form

by Lloyd Hofmeyr Molefe
an Authorised Financial Services Provider (FSP)
FAX TO: (+27) 0866 196014 • POST TO: Suite 42, Private Bag X18, Rondebosch, 7701
QUERIES: 0861 723324 (office hours)
 Personal Details  (Fields with * are compulsory)
Title*
 
Passport Number
 
Name*
 
Passport Nationality
 
Date of Birth*
 
Date of Arrival in SA*
 
Contact Telephone Number*
 
Date of Departure from SA *
 
Postal Address




(where Safari ID / ER24 ID Pack will be sent)
Email Address*
 
(where SafariMED Policy will be sent)
 Emergency Details and Contacts (to be completed by SafariID applicants only)
Resident Doctor Name
 
 
Doctor Tel No
(Int Code)  
 
(Tel No)   
 
Next of Kin Name
 
Next of Kin Tel No
(Int Code)  
 
(Tel No)   
 
 If you have any medical conditions (eg allergies, medications etc) that you would like noted on your Datafile; list here

 

 
 If you already have travel cover; provide us with details, which we will record on your Datafile
Name of Insurer
 
Policy Number
 
 SafariMED Inbound Option chosen (tick one)
    
SafariMED with Safari ID
    
SafariID only
    
SafariMED only
 SafariMED Luggage option chosen (tick one)
    
Not chosen
    
Option 1 (R7500)
    
Option 2 (R5000)
    
Option 3 (R3000)    
 Payment Details (please tick prefered method of payment)
    
Credit Card
Card Type
    
 Visa
    
Mastercard
Name on Card
 
Card Number
 
Expiry Date
 
3 Digit Security No (CVV)
 
    
Direct Transfer
 


Payment to be made to:
Lloyd Hofmeyer Molefe
First National Bank
Rondebosch
A/C No. 50170108317

Fax proof of payment to:
(+27) 0866 196014
Please Note - SafariMED policy will be forwarded within 24 hours of confirmation of Payment