South African Breweries Medical Aid Scheme Administered by: Momentum Medical Scheme Administrators PO Box 2338, Durban, 4000 Tel: 0860 00 21 33 Fax: 031 580 0478 Email: firstname.lastname@example.org APPLICATION FOR MEMBERSHIP ID Documents, birth certificates and marriage certificates are required for principal member and dependants. PERSONAL PARTICULARS APPLICANT SPOUSE Surname Surname First name First Name Gender M F Gender M F Date of Birth D D M M Y Y Date of Birth DDMMYYYY Identity No. I.D.No. Relationship MARK APPLICABLE BOX WITH AN “X” DEPENDANT 1 Single Married Divorced Widow(er) Surname Partner First Name Gender M F Date of Birth CONTACT DETAILS D D M M Y Y Postal Address Identity No. Relationship Code DEPENDANT 2 Physical Address Surname First Name Code Gender M F Date of Birth D D M M Y Y Telephone (H) Identity No. Telephone (W) Relationship Cell: DEPENDANT 3 E-mail Surname First Name Gender M F Date of Birth D D M M Y Y Please note: We reserve the right to request additional Identity No. information if required Relationship DEPENDANT 4 Surname First Name Gender M F Date of Birth D D M M Y Y Identity No. Relationship EMPLOYER INFORMATION TO BE COMPLETED BY BENEFIT FUNDS ADMINISTRATOR / PAYROLL SUPERVISOR 1. Name of employer : 2. Te lephone Number : 2. Group number : 3. Applicant’s employee number : DD/MM/YYYY 4. Applicant commenced employment on : 5. Applicant’s Occupation : 6. Salary : DD/MM/YYYY 7. Date this contract is to start : ALL INFORMATION GIVEN ABOVE IS CERTIFIED CORRECT SIGNED ON BEHALF OF THE COMPANY/EMPLOYER : SIGNATURE COMPANY NAME OF SIGNATORY : STAMP DATE : PREVIOUS MEDICAL AID HISTORY Please give full details of your membership of any other medical scheme (s) during the past two years and provide proof by attaching your certificate(s) of membership. NAME OF SCHEME MEMBERSHIP NUMBER MEMBERSHIP ON DATE OFF DATE STATE OF HEALTH PRE-EXISTING CONDITIONS I am bound now, and in the future, if I am accepted as a Member, to give the Scheme and/or administrator all such information and evidence as the Scheme may from time to time require. To this end I authorise the medical practitioner or other Provider who has the attended me or my dependants in the past or who will attend me or my dependants in the future to provide the Scheme with such information as may be required , hereby waiving the provisions of any law or regulations restricting the giving of such information. My dependants and I will also submit, as and when required by the Scheme, to an examination by the Scheme's Medical Assessor. Has any person during the 12 months prior to your making this application recommended that you take medical advice, diagnosis, care or treatment ? If so, please give full details. Y/N Have you at any stage during the 12 months prior to this application known that you ought to take medical advice, diagnosis, care or treatment but, for whatever reason, failed to do so? If so, please give full details. Y/N UNDERWRITING QUESTIONS Please complete all questions below if there has been a change in your health status or that of your spouse or dependants since the date of your application to SAB Medical Aid Scheme. Failure to disclose any pre-existing conditions could result in benefits being limited, excluded and/or your membership being terminated. PLEASE ANSWER “YES” OR “NO” FOR EVERY QUESTION (”Y” or “N”) 1 High blood pressure, high cholesterol or lipids, ischaemic heart disease, heart failure, angina, stroke (CVA) or peripheral vascular disease 2 Obstructive lung disease (asthma, emphysema, COPD) 3 Diabetes (insulin or non-insulin dependant diabetes mellitus) 4 Hypo or hyperthyroidism 5 Arthritis, i.e. osteo, rheumatoid, or gout - all related musculoskeletal conditions 6 Osteoporosis 7 Gastro-oesophageal reflux disease (GORD, heartburn) or stomach or duodenal ulcers (please circle) 8 * Immune deficiency status, i.e. HIV / AIDS *, immunoglobulin deficiencies 9 Anaemia or abnormalities of clotting mechanism 10 Hormone replacement therapy, endometriosis or ovarian cysts 11 Depression and/or anxiety disorders 12 Any nervous or mental complaint, e.g. epilepsy, blackouts, paralysis or headaches 13 Glaucoma, cataracts or any other disorders of the eye 14 Parkinson’s disease or multiple sclerosis (please circle where applicable) 15 Hyperplasia of prostate (BPH) or prostatism 16 Inflammatory bowel disease (Crohns disease or ulcerative colitis) 17 Urinary tract infection or calculi (stones) 18 Back or neck related condition (lumbago, sciatica, injury, spasm, etc) 19 Are you pregnant? If so, how many weeks? 20 Have you had any surgical procedures during the past 12 months or are you planning a surgical procedure for the following 12 months? 21 Are you on any medication at present? 22 Is there any other condition of symptom, which is not detailed above, for which medical advice, diagnosis, care or treatment has already been recommended or received, or could potentially result in a medical aid claim within the next 12 months? 23 Skin conditions/disorders, e.g. acne, eczema, psoriasis, etc 24 Ear, nose or throat disorders, e.g. ear discharge, recurrent tonsillitis 25 Infectious diseases, e.g. tuberculosis, shingles, measles, etc 26 Malignant neoplasms (cancer, growths or malignant tumours) 27 Benign neoplasms (non-malignant tumours/growths) 28 Specialised dentistry / maxillo facial treatment 29 Have you had or are you expecting to have plastic or reconstructive surgery? DO YOU OR YOUR DEPENDANTS TAKE CHRONIC MEDICATION? Y/ N continued on next page IF YOU HAVE ANSWERED YES TO ANY OF THE ABOVE THE FOLLOWING DETAILS ARE TO BE PROVIDED. FAILURE TO DISCLOSE ANY PRE-EXISTING CONDITIONS COULD RESULT IN BENEFITS BEING LIMITED, EXCLUDED AND /OR MEMBERSHIP TERMINATED. Question Nature and duration of complaint and full details of treatment Name and telephone number of When last did you have symptoms No. being received or expected to be received attending doctor or hospital or last receive treatment? *HIV / AIDS information can be faxed confidentially on 031 580 0484. BANKING DETAILS OF APPLICANT (For direct payment of refunds due to you). Name of Account Holder Bank & Branch Name Branch Number Account Number Account Type (C=Current, T=Transmission, S=Savings) ONLINE ACCESS Would you like access to your information on the SAB Medical Aid Scheme website? YES NO E-mail address Preferred User Name OPTION SELECTION: Please indicate which option you are joining by placing a cross (x) in the appropriate box below : SAB OPTION CASTELLION OPTION WAITING PERIODS Subject to the terms and conditions applicable to the admission of other members, persons who have been members of any other medical scheme for at least two years and whose application for membership is made within three months of ceasing to be members of the other scheme, will be admitted without waiting period or the imposition of new restrictions, provided a Certificate of Membership is furnished. Membership cards ae not acceptable - certificates only please. In the case of new members who have not been members of any another schemes for two years, or who have had a break between membership of schemes of more than three months, the folllowing waiting periods will apply: General Waiting Period (All Benefits) - 3 months Condition Specific Waiting Period - 12 months (for any pre-existing conditions) ACKNOWLEDGEMENTS 1. I acknowledge that I am aware of the provisions of the South African Breweries Medical Aid Scheme Rules dealing with undesirable business practices, the submission of fraudulent claims to the Scheme. the commission of fraudulent acts and the non-disclosure of material information to the Society. In particular, I am aware that I am not permitted to allow any person other than my dependants to use my membership card. 2. I am aware that, if I am accepted for membership, the South African Breweries Medical Aid Scheme Rules will be binding on me and that, on admission to membership, a summary of the benefits and contributions will be provided to me. 3. I hereby authorise and instruct my Employer to deduct from my remuneration and any other sums due to me, any amounts which may be due by me to the South African Breweries Medical Aid Scheme from time to time and to pay to the same to the Scheme. Likewise, I hereby authorise and instruct any person (such as my Employer or a pension fund or provident fund) who holds funds for my benefit after I cease employment, to pay and continue to pay, the amounts referred to in the first sentence hereof to the Scheme as and when they fall due. 4. I am aware that proof of identification may be requested at any stage. 5. All sums due by me to the South African Breweries Medical Aid Scheme shall be forthwith due and payable by me to the Scheme immediately upon my ceasing to be a Member. ONLINE ACCESS •. I accept that the Scheme will not in any way be responsible or liable for any claims of any nature whatsoever made by anyone (myself excluded) which arise as a result of my failing to keep my password and user name secure and confidential to myself. •. I indemnify the Scheme and hold it harmless against any such claims. •. I understand that this service may not be available 24 hours a day. Signature Date Signed by me as Applicant, declaring that I have carefully read this application form and accept all terms and conditions. Membership will only be awarded upon receipt of a fully completed application form. Incomplete forms will be returned to you.