SafariMED Outbound Travel Cover
Application Form

by Lloyd Hofmeyr Molefe
an Authorised Financial Services Provider (FSP)
FAX TO: 0866 196014 • POST TO: Suite 42, Private Bag X18, Rondebosch, 7701
QUERIES: 0861 723324 (office hours)
Personal Details  (Fields with * are compulsory)
Title*
 
Name*
 
Date of Birth*
 
Nationality
 
Country of destination*
 
Date of Departure*
 
Date of Arrival back in SA*
 
Contact Telephone Number*
 
Email Address*
 
(where Policy will be sent)
SafariMED Outbound Option chosen (tick one)
    
Leisure
    
Leisure PLUS
    
Business
    
African Value
    
Youth
SafariMED Luggage option chosen (not available on Youth option) (tick one)
    
Not chosen
    
Option 1 (R7500)
    
Option 2 (R5000)
    
Option 3 (R3000)    
Method of Payment (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:
0866 196014
Please Note -Your SafariMED policy will be forwarded within 24 hours of confirmation of Payment