MEMBER AND DEPENDANT APPLICATION FORM



 
Name of company:
Date of commencement:

Option

Checklist documentation to accompany this application





Employer Details

Name of employer :
Contact person :
Postal address :
Postal Code :
Email address :
Contact details : Tel :
Fax :
Cell :

Principal Member Details

Surname :
 
First name /s :
 
Title :
 
Martial status :
Nationality :
Present age :
Date of birth :
 
Id/Passport number :
 
Tax number :
Race :
Height(cm):
Weight(kg):
Smoker:
Postal address :
 
 
Postal code :
Physical address :
 
 
 
 
Postal Code :
Email address :
Telephone details (B):
(H):
Facsimile details (B):
Cell :
 
Occupation :
 
Date employed :
 
Income : R :
 
Name of GP :
GP Telephone No :
GP Practitioner No :

Spouse / Partner details

Surname :
First name /s :
Title :
Martial status :
Nationality :
Present age :
Date of birth :
Id/Passport number :
Tax number :
Race :
Height(cm):
Weight(kg):
Smoker:
Telephone details (B):
(H):
Facsimile details (B):
Cell :
Occupation :
Date employed :
Income :R :
Name of GP :
GP Telephone No :
GP Practitioner No :

Medical History Questionnaire

It is most important that the questions on the following page be answered as thoroughly as possible. The answers to these questions will be treated as confidential. It is important to note that any medical condition, of which you are aware, not disclosed in this application, can be excluded from benefit. Please advise whether you or any of your dependants suffer from, or have suffered from, or received treatment / consultation for any of the following conditions. Please ensure that you tick and complete the appropriate block / s.

Answer yes or no to all questions
 
 
 
Name of member / dependant
Heart & Vascular System
High blood pressure; high cholesterol; angina; heart attack; angiogram; previous coronary artery bypass; rheumatic fever; heart murmurs; valve problems / replacement; arrhythmias – insertion of pacemakers; heart failure; stroke; varicose veins; DVTs (deep vein thrombosis); pulmonary embolism.
 
Lungs
Asthma; emphysema; chronic bronchitis; TB; chronic infections - bronchitis & pneumonia.
 
Digestive System, Gallbladder; Liver
Dyspeptic disease (heartburn; hiatus hernia; peptic ulcers; reflux); irritable bowel syndrome (spastic colon; inflammatory bowel disease e.g. CHRON’S & ulcerative colitis; chronic diarrhoea / constipation); gallstones & jaundice; hepatitis; pancreatitis; haemorrhoids; incontinence; bowel prolapse.
 
Nervous System
Persistent headaches; epilepsy; paralysis; degenerative diseases – Alzheimer’s; Parkinson’s; multiple sclerosis; stroke; neuralgias; ADD (attention deficit disorder).
 
Bone; Muscle & Joints
Arthritis; rheumatism; gout; back, knee or neck problems; fibromyalgia; previous fractures; deformities; degenerative muscle disease; osteoporosis; previous amputations / artificial limbs; birth defects; joint replacements.
 
Urinary Tract
Infections; stones; albumin / blood in urine; urinary incontinence; prolapsed bladder.
 
Gynaecological System
Menopause; female hormone replacement; irregular menses; infertility; breast tumours (benign / malignant); ovarian tumours; cysts; prolapsed uterus / rectum / bladder; miscarriage; caesarean section.
 
Male Genital System
Prostate problems (hypertrophy / cancer or infections); infertility; hernias – groin; scrotal swellings; testicular tumours; abnormalities of the penis. TEST
 
Gland / Hormonal
Over / under active thyroid; diabetes mellitus; Cushing’s syndrome; Addison’s disease; pituitary gland abnormality.
 
Blood
Anaemia; bleeding disorders (haemophilia); leukaemia; Hodgkin’s disease.
 
Ear, Nose & Throat
Allergies (rhinitis, sinusitis); chronic infections (otitis, tonsillitis); nasal reconstruction; snoring; sleep apnoea; deafness – hearing aids.
 
Eyes
Poor vision; birth defects; degenerative disease (glaucoma; retinitis pigmentosa; cataracts; keratoconus); allergies – pterygiums; anticipated / previous laser surgery; artificial eyes.
 
Emotional (psychological, psychosomatic problems)
Depression; bipolar disorder; anxiety; stress; previous treatment for post traumatic stress syndrome; eating disorders – bulimia & anorexia; mental retardation; alcoholism; drug abuse.
 
Infections / Tropical Diseases
Sexually transmitted diseases; genital warts; HIV / AIDS; hepatitis; ME-Virus (Yuppie Flu); malaria; bilharzias; cholera; typhoid.
 
Skin Disorders
Acne; eczema; psoriasis; lesions (keloid hypertrophic scars); skin rashes; shingles; Kaposi sarcoma – tumours.
 
Connective Tissue Disorders
Systemic lupus erythromatosis; scleroderma.
 
Teeth & Gums
Impacted molars (wisdoms); previous / current orthodontic treatment; braces; crowns; recurrent infections - gums.
 
Cancer
Cysts; growths; tumours of any kind.
 
Allergies
Are you or any of your dependants allergic to any specific type of medication (e.g. penicillin, aspirin, sulphas, morphine, NSAIDS); pollen dust; animals; specific food types (e.g. nuts).
 
Immuno-Suppressive Treatment
Have you or any of your dependants ever had or expecting to undergo an organ treatment transplant? Have you or any of your dependants ever suffered from any condition requiring Immunosuppressive treatment?
 
Have you or any of your dependants ever received any form of physiotherapy, occupational therapy or chiropractic treatment?
Are you or any of your dependants pregnant? If yes - how many weeks? Please give expected date of delivery.
Have you or any of your dependants had any previous or pending claims for which any other party may be liable e.g. MVA (Motor Vehicle Accident) claims? If yes, please give details.
Are you or any of your dependants expecting to undergo any medical treatment, e.g. hospitalisation, operation, specialised dentistry etc, within the next twelve months?
Do you or any of your dependants have a chronic condition requiring ongoing medication? If yes, please give the name and dosage of all the medication you or any of your dependants are currently taking.
Have you or any of your dependants ever received any medical attention of any nature, e.g., hospitalisation, operation, specialised dentistry etc, not mentioned above?
Have you and any dependants ever appeared before a medical board in view of early retirement and declared medically unfit?

Electronic transfer information

 
PAYMENTS (Claims refunds)
 
COLLECTIONS (Members portions)
Account Holder :
Account Holder :
Account holder ID:
Account holder ID :
Bank Name:
Bank Name:
Branch:
Branch:
Branch number:
Branch number:
Account number:
Account number:
Type of account:
Type of account:

Method of payment of contribution

Please select method of payment:
 

Broker declaration and details

WHERE A BROKER HAS BEEN USED, THE BROKER MUST COMPLETE THE FOLLOWING BROKER DECLARATION SECTION:

  1. I hereby confirm that I have been appointed by the member applicant, and acknowledge that the member applicant may terminate my services at any time.
  2. I confirm that I am fully accredited in terms of relevant legislation, on date of my signature, of this document.
  3. Financial Services Board: Accreditation number
    Council for Medical Schemes: Accreditation number
  4. I confirm that I have provided the member applicant with my full name, physical and postal address and telephone number.

  5. The commission payable upon completion of the transaction by the: Member applicant     R
    Scheme R
  6. I confirm that I have a valid contract with the scheme.
  7. I confirm that the information provided by me, to the member applicant and the scheme is true and correct to the best of my knowledge.
  8. I confirm that where I have completed this application form on behalf of the applicant member, the applicant member is familiar with the information requested and responses provided.
  9. The advice and assistance provided to the applicant member was impartial and in his / her best interests.
  10. In the event of a material misrepresentation being made by me or engagement in unlawful conduct I undertake to refund all monies paid by the applicant member and / or the scheme in consequence of such misrepresentation or conduct.

DISCLAIMER: The scheme shall not be held responsible for any misrepresentation made by any of its agents / representatives / consultants.

Broker Details

Brokerage name:
Broker code:
Broker’s name:
Broker's cell:
Brokers Tel. Code ( ):

Broker Consultant

Broker consultant name:
BC code: