Application Form

Contact Me

If you would like to download a PDF version of the application form please click on the link below and either save it to your computer (for later use) or print a copy:

Please be sure to attach the following documentation to your application:

  • ID/Birth/Passport document (of member and dependants)

  • Legal adoption documents (if children are adopted)

  • Marriage Certificate (Spouse)

  • Student Letter (annually, for children who are studying)

  • Affidavit, should any dependant's surname differ from principal member's surname

  • Membership Certificates of all previous medical aids prior to joining Suremed (Require proof for the last two years)

  • The health questionaire (Medical History) has to be completed in full by indicating YES or NO to all questions. If YES, details need to be provided in the section specified. The Health Questionaire can be downloaded here: Health Questionaire.pdf

Your Chronic application can be submitted in one of the following ways:

Fax:(041) 395 4596/7
E-mail:[email protected]
Post:P.O. Box 1672
Port Elizabeth