Get NA Travel Declaration Form for NMC Members

TRAVEL DECLARATION FORM for NMC members Your Medical Scheme membership entitles you to International Travel Insurance. This policy will insure you and your dependants as listed under your Medical Aid membership against emergency medical expenses that may be incurred while traveling abroad for trips of up to 90 days at a time. In order to activate this benefit please complete the form below. Once the form has been completed please fax to 264 61 287 6091 or email to enquiries methealth. com*na* A policy document confirming your emergency medical cover will be issued and sent to you. Please note Should you have any queries or in case of emergencies please contact the Travel Guard Chartis 24 hour emergency medical assistance call centre on 44 1273 739 274 or the South African number 27 11 525 3109 Application For International Emergency Medical Expenses Cover Scheme Membership Number Please complete main member dependant details below Title Firstname Lastname Date of birth Telephone No Fax No Email address Departure Date from home Return Date Return to home Countries to be visited House Doctor Name and tel Next of Kin Telephone number Passport Nr Please indicate with an asterisk to which e-mail/fax the Travel Protection Certificate must be sent Fax to. This policy will insure you and your dependants as listed under your Medical Aid membership against emergency medical expenses that may be incurred while traveling abroad for trips of up to 90 days at a time. In order to activate this benefit please complete the form below. Once the form has been completed please fax to 264 61 287 6091 or email to enquiries methealth. In order to activate this benefit please complete the form below. Once the form has been completed please fax to 264 61 287 6091 or email to enquiries methealth. com*na* A policy document confirming your emergency medical cover will be issued and sent to you. Please note Should you have any queries or in case of emergencies please contact the Travel Guard Chartis 24 hour emergency medical assistance call centre on 44 1273 739 274 or the South African number 27 11 525 3109 Application For International Emergency Medical Expenses Cover Scheme Membership Number Please complete main member dependant details below Title Firstname Lastname Date of birth Telephone No Fax No Email address Departure Date from home Return Date Return to home Countries to be visited House Doctor Name and tel Next of Kin Telephone number Passport Nr Please indicate with an asterisk to which e-mail/fax the Travel Protection Certificate must be sent Fax to. This policy will insure you and your dependants as listed under your Medical Aid membership against emergency medical expenses that may be incurred while traveling abroad for trips of up to 90 days at a time. In order to activate this benefit please complete the form below. Once the form has been completed please fax to 264 61 287 6091 or email to enquiries methealth. com*na* A policy document confirming your emergency medical cover will be issued and sent to you. Please note Should you have any queries or in case of emergencies please contact the Travel Guard Chartis 24 hour emergency medical assistance call centre on 44 1273 739 274 or the South African number 27 11 525 3109 Application For International Emergency Medical Expenses Cover Scheme Membership Number Please complete main member dependant details below Title Firstname Lastname Date of birth Telephone No Fax No Email address Departure Date from home Return Date Return to home Countries to be visited House Doctor Name and tel Next of Kin Telephone number Passport Nr Please indicate with an asterisk to which e-mail/fax the Travel Protection Certificate must be sent Fax to. .