Membership Application Form (Local Government)
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Transcript of Membership Application Form (Local Government)
7/26/2019 Membership Application Form (Local Government)
http://slidepdf.com/reader/full/membership-application-form-local-government 1/2
The Medical Schemes Act requires that a copy of the Principal Member and all Dependants' identity documents and confirmation of previous medical
scheme coverage must be attached
Application for Membership
86 Koranna Avenue Doringkloof Centurion 0157 PO Box 14145 Lyttelton 0140 Application Enquiries: 0860 873 628 Fax: 086 605 0656
Instructions1.
2.
Please complete every section below in full. If not applicable, please write N/A in the appropriate field.
Section 1: Option Choice
Silver Option
Essence Option
Origin Option
Gold Option
Platinum Option
Equilibrium Option
Important note: The Principal Member may make an option change only as from 1 January of each year
Residential address
Passport number Marital status
Postal code
Postal code
Postal address (if different)
E-mail address
Fax - work (code - number)
Cellphone number
Language preference English Afrikaans
Telephone - work (code - number)
Telephone - home (code - number)
Section 2: Personal Details (attach copy of ID / Passport)
Principal Member
Y Y M M D D
Title
Please indicate your monthly income:
* Valid proof of income needs to be attached to this application. Failure to do so will result in you being placed on the highest income level.
First name
Surname
Initials
ID number FemaleMaleGender:
Dependants (attach copies of ID / Passport or Birth Certificate)
First name
1.
2.
3.
4.
ID No./Passport No. Date of BirthSurname, if different from
Principal Member Relationship to
Principal Member Gender (M/F)
Y
Y
Y
Y
Y
Y
Y
Y
M
M
M
M
M
M
M
M
D
D
D
D
D
D
D
D
*An Applicant may be requested by the Scheme to confirm relationship to Principal Member.
5.
6.
Y
Y
Y
Y
M
M
M
M
D
D
D
D
KH2014/02 Page 1 2
7/26/2019 Membership Application Form (Local Government)
http://slidepdf.com/reader/full/membership-application-form-local-government 2/2
Section 3: Financial Advisor
Name
Email Address
Broker Code Accreditation Number
Telephone number (code - number)
Page 2 2
Application will not be processed without banking details. Attach a copy of a cancelled cheque / a latest bank statement / anofficial bank letter for verification purposes. In case of a savings or transmission account, please ensure that the informationis absolutely correct as the Scheme will not accept responsibility for amounts transferred to wrong accounts.
Name of account holder
Name of financial institution
Branch code Branch name
TransmissionSavingsCurrent
Account number
Account type
Account Holder Signature Date _ _
2 0D M Y YMD
Section 4: Details of Principal Member for Claims Reimbursement
*Please note that no credit card banking details will be accepted
Section 5: Employer Information - To be completed by employer
Company Name
Group number (for official use only)
Employee number
Branch name Branch number
Principal Member's occupation
Business telephone number (code - number)
Date of employment _ _
MD D YY Y YM
Date _ _
2 0D M Y YMD
SIGNATURE AND STAMP OF EMPLOYER
DESIGNATION
Section 6: Declaration by Principal Member
Signature ofPrincipal Member Date
_ _ 2 0D M Y YMD
I declare that6.1
I undertake to familiarise myself with the latest Rules of the Scheme as amended from time to time;6.1.1
I am familiar with the conditions and benefits of the option selected, notwithstanding representation by any other party;6.1.2
I fully understand the implications of moving from one scheme to another;6.1.3
Admission to the Scheme is not subject to the services of a broker being employed;6.1.4
I understand the role of my broker (if applicable).6.1.5
Signature ofFinancial Advisor Date _ _ 2 0D M Y YMD
I request the Scheme to register me and my dependants from6.1.6 _ _ 2 0D M Y YMD