Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out

APPLICATION FOR CORPORATE MEMBERSHIP

VIEWS: 21 PAGES: 4

APPLICATION FOR CORPORATE MEMBERSHIP

More Info
  • pg 1
									BESTmed 1/Corporate

APPLICATION FOR CORPORATE MEMBERSHIP
Administered by Sanlam

FOR OFFICE USE ONLY Member no Org. no Subcode Date of admission Subscription

Benefit option ______________________________ Savings level ______________________________
To be completed by applicant, complete sections 1-4,6-9

Salary code ___________________________________ Pers. no ______________________________________

1. APPLICANT (PRINCIPAL MEMBER) write in BLOCK LETTERS Title ______________________________________ Surname _____________________________________

Full names _______________________________________________________________________________ Date of birth of member
D D M M Y Y Y Y

Language preference

Eng D

Afr D M M Y Y Y Y

Marital status _______________________________ Date of marriage/divorce ID number (need copy of ID/Passport) 2. ADDRESS AND CONTACT DETAILS (PRINCIPAL MEMBER) Residential address _________________________ _________________________________________ _________________________________________ ___________________ Postal code Tel (w) ___________________________________ Cell _____________________________________ 3. DEPENDANT(S)
Name Surname
if different from principal member

Gender

M

F

I want my medical correspondence to be sent to _____________________________________________ _____________________________________________ _______________________ Postal code Tel (h) _______________________________________ E-mail _______________________________________

Gender M M M M M F F F F F

ID-number

Relationship
Spouse Partner Child Other Spouse Partner Child Other Spouse Partner Child Other Spouse Partner Child Other Spouse Partner Child Other

Declare other

4. ATTACH THE FOLLOWING DOCUMENTS IF APPLICABLE • A copy of the ID/Passport of dependant(s). • If a child is >21 - proof of full time registration. • Extended family - declaration of dependant(s)
2297, Pretoria, 0001 2008/07/31ZP 551 Belvedere Street, Arcadia, Pretoria +27 12 339 9800 +27 12 339 9900 service@bestmed.co.za www.bestmed.co.za 086 000 2378/086 000 BEST

To be completed by Employer

5. STATEMENT BY EMPLOYER RELATING TO APPLICANT Employers name __________________________________ Employer code Human Resources Practitioner name ____________________________ Contact number ________________ a. Has been permanent in our employ from b. Date of enrolment c.
Benefit option Blueprint Blueprint Millennium Basic Millenium Standard Bonus Plus Millenium Comprehensive Topcare Preferred network Prime cure CareCross
Provider’s name Practice no

D Y Y

D M M

Y

Y

Y

Y

D

D M M

Y

Y

Annual income interval na na 0 - R78 000 0 - R54 000 0R33 600 > R78 001 > R54 001

Annual savings account None None Compulsory Compulsory Compulsory Compulsory Compulsory

na na na na na

R33 601 R39 601 R45 601 R39 000 R45 000 R51 000 > R72 001 na na > R72 001

0 - R72 000

d. Salary per annum __________________________________________________ at the date of employment e. Department ____________________________________________________________________________ f. Personnel number _______________________________________________________________________

g. Total monthly contribution to be paid to BESTmed ( R ____________________________,______________ ) Signature of Human Resource Practitioner _____________________________ Date 6. PREVIOUS REIMBURSEMENT NB: If you and/or your spouse/partner and/or dependant(s) are/is at present a member/dependant of a medical scheme or were/was a member/dependant of a medical scheme/s in the past two years, a CERTIFICATE OF MEMBERSHIP for every person should accompany the application form. (NB: Not a member card!) If “Yes” please state Scheme details Name of scheme Member number
D D M M Y Y Y Y

Status Member Dependant

Period From To

7. MEDICAL HISTORY OF APPLICANT AND DEPENDANTS Please Note: All questions in the medical history questionnaire must be answered by stating YES or NO. In case of a YES, the full details of the relevant person must be furnished in the space provided. If you or any of your dependant(s) are suffering from a chronic condition, a medical report is required setting out details of the condition as well as the estimated annual cost of treatment therof. If the space provided is insufficient, write details on a separate page and attach to this questionaire. Height of applicant (cm) ____________________ Current weight of applicant (kg) _______________________ Estimated total cost of medical services rendered to your dependant(s) in the past two years. Year ____________________ R __________________ Year ___________________ R _________________ (Attach summary statement if your dependant(s) belonged to another medical scheme).
2008/07/31ZP

MEDICAL QUESTIONNAIRE

Have you or your dependant(s) received any medical treatment or care in the past 12 months or medical advice relating to any of the following conditions? (Refer to question 1-20. Question 21 excluded) 1. Congenital physical deviations e.g. bat-ears, valvular heart disease

Indicate with a “X” in the appropriate column

Condition Name of patient

Date

Period

Level/stage of illness, condition, nature of treatment, medication dosage and hospitalisation

YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO

NO

2. Abnormality of skin (including allergies) e.g. eczema, psoriasis 3. Deviations in skeleton, joints and muscles e.g. arthritis, back problems 4. Sense organs: sight, hearing, speech, also state spectacles and/or contact lenses as well as visual strenght reading if available 5. Respiratory organs and cardio-vascular systems e.g. hypertension, cholesterol, asthma 6. Digestive system e.g. hiatus hernia, stomach ulcer 7. Bladder, kidney and sexual system 8. Nervous system e.g. paralysis, epilepsy 9. Hormone system 10. Psychiatric or psychological treatment e.g. depression. anxiety 11. Substance dependance e.g. alcohol, drugs 12. Dental treatment 13. Metabolic diseases, obesity, diabetes, porphyria 14. A condition for which you and your dependant(s) receive a payment and/or medical treatment of whatever nature e.g. IOD claim, third party claim 15. Are you or your dependant(s) pregnant or is there any suspicion of pregnancy? 16. Previous abnormal pregnancies 17. Contagious diseases e.g. HIV, Hepatitis B, Tuberculosis 18. Operations undergone 19. Are you and/or your dependant(s) currently being treated for something? 20. Present medication 21. Any other medical condition not mentioned above, even though you or your dependant(s) did not receive treatment or advice or consulted a doctor in the past 12 months 22. Do you and/or your dependant(s) participate in professional or dangerous amateur sport, like power-driven vehicle sport, glider sport, scuba diving, bungee or parachute jumping? If so, provide detail:

Nature of the sport

Person(s) participating

Injuries

YES

NO

Date D D M M Y Y Y Y
2008/07/31ZP

Signature of member ___________________________________________________________

3

8. STATEMENT OF APPLICANT I, ________________________________________________________________________ hereby declare that: a. Should I be enrolled as a member of BESTmed, I shall subject myself to the rules of BESTmed; b. The information furnished herein is completely true and correct to the best of my knowledge and conviction and that I have not omitted or concealed any information, I unconditionally accept membership for 12 months and understand that a savings account will be allocated pro rata (if applicable); c. I understand that should my application for memebership be approved and accepted, the information furnished on my application form will be used as the basis of my application and the payment of benefits in the future; d. I irrevocably hereby grant permission on myself as well as my dependant(s) behalf (if applicable) to any physi cian, person or party who may be in possession of or obtain information concerning my state of health or that of my dependant(s), treatment received or expected as well as any other relevant information to divulge such information to BESTmed or its proxy or demand, also after my death or that of my dependant(s), I understand that this information together with other information will be used to evaluate the payment of benefits for certain sickness conditions, I guarantee that I have obtained my dependant(s) consent to grant this authorisation: e. I undertake to pay my share of accounts to BESTmed, on default, I hereby authorise my employer/undertaking to deduct the amount due from my salary or should I resign, I hereby authorise my employer/undertaking to deduct the amount due from my pension or any other moneys due to me and pay this over to BESTmed; f. If after my admission as a member of BESTmed it is found that any statement or information furnished by me was knowingly and willfully inadequate or untrue, I agree to refund in full to BESTmed all payments which BESTmed may have made on my behalf and to relinquish any claim to any benefits on the part of BESTmed and; g. Any deterioration or change in my state of health or in that of any dependant(s) before the date or event to be set by BESTmed for commencement of membership, or the date of acceptance of this application by BESTmed, or the date of receipt of the first subscription, whichever date is the latest shall entitle BESTmed to reconsider the application and propose new terms of admission or declare the membership null and void in which case all moneys paid to BESTmed in connection with this membership before BESTmed is informed of the change, shall be forfeited and benefits paid by BESTmed shall immediately be refunded to BESTmed; h. BESTmed reserves the right to cancel membership should ir become apparent that false information was willingly supplied on application. 9. CLAIM REIMBURSEMENT DETAILS Details of my/our bank account ________________________________________________________________ Account holder ______________________________________________________________________________ Bank ______________________________________________________________________________________ Branch name and town _______________________________________________________________________ Account number Branch number Type of account Current (cheque) Savings Transmission (Mark applicable block)

Title ________________________________________ Surname ______________________________________ Full names _________________________________________________________________________________ ID number Date
D D M M Y Y Y Y

Signature of applicant __________________________ Signature of witness ______________________________

2008/07/31ZP


								
To top