ONLINE APPLICATION FORM

    APPLICANT INFORMATION

    ARE YOU A MEMBER OF THE FOLLOWING ORGINISATIONS?



    SPOUSE INFORMATION

    CHILDREN INFORMATION

    DEBIT ORDER DETAILS:

    ARE YOU THE PREMIUM PAYER?

    I hereby irrevocably authorize ACA to debit my account with:

    R35 PER MONTH FOR THE FAMILYR350 PER YEAR FOR THE FAMILY

    The family membership includes the main member, spouse (any person to whom you may be married in terms of South African law, including a party to a customary union according to ethnic law and custom or to a union recognised as a marriage under the tenets of any Asiatic religion, or a person with whom you share a common home with pooled resources, with the intent that this arrangement is permanent), and any dependent child under the age of 18 years, (including adopted, foster and step children, as well as children who are totally physically and/or mentally handicapped and reliant permanently on the support of the main member) who reside in the same residence as the main member. PAYMENT: Your contribution of R35.00 OR R350.00 will be deducted directly from your bank account. You pay contributions monthly in advance. This means that the deduction in the month is your contribution for the next month. A waiting period of three (3) months is applicable to members paying monthly premium, wherein no claim may be lodged for an accident occurring within the waiting period. Members paying a yearly premium will have immediate coverage.

    Allow ACA correspondence via email

    YESNO

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