Co-Members included

Monthly Membership Fees

• Option 1: CMR Household Membership WITH Hospital Transport Cover: R360 per household per month (6 people max - see pricing below for additional people living on premises)
• Option 2: CMR Household Membership WITHOUT Hospital Transport Cover: R255 per household per month (I understand the cost of ambulance transport to hospital will be billed separately if/when required)
• Option 3: Pensioners' Household Membership WITH Hospital Transport Cover: R335 per household per month (max 2 people, at least one person must be 65 or above)
• Option 4: Pensioners' Household Membership WITHOUT Hospital Transport Cover: R230 per household per month (I understand that the cost of ambulance transport to hospital will be billed separately if/when required)

SELECT ONE OF THE OPTIONS THAT WOULD SUIT YOUR NEEDS

IF MORE THAN 6 PEOPLE NEED COVER AT THE PROPERTY INDICATE BELOW HOW MANY TO ADD AT AN ADDITIONAL COST OF R50.00 PER PERSON

Membership for Domestic workers who live off the property @ R66 p/person p/month

Please note mebership becomes active on receipt of this application. If you would like to activate the membership at a later date please indicate such date below

Person responsible for account

Preferred debit date

By submitting this form, I/we agree to subscribe to the service for two years in accordance with CMR's Standard Terms & Conditions which are available on request and on CMR's website: www.cmr-med.co.za I/we confirm that I/we have read and understood the terms and conditions and agree to the terms thereof.

I/we hereby authorize Cape Medical Response to debit my/our account with the total monthly premium indicated above, and in the starting month
indicated above. I/we understand that a charge of R120 will be levied for any debit-order non-payment/s.

Please note this form will only be sent if you have ticked the "I'm not a robot" box above AND clicked on the "submit" button below.
Should you not hear from us within 24 working hours something is not right - please call us on 021-7820606 or email mark@cmr-med.co.za