MEMBER AND DEPENDANT APPLICATION FORM

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NEW APPLICATIONNEW DEPENDANTName of companyName of individualDate of commencementMembership number:DDYYMMOption (please tick the appropriate box)PinnacleDynamix SymmetryMumedAxis NetworXUniSaveNetworX Option: Members are required to nominate a General Practitioner (per beneficiary) from the list of approved network service nameName of nominated GPAddress of nominated GPGP practice numberGP telephone numberMumed / NetworX applications Copy of 3 latest salary slips, IRP 5 or IT 34Membership certificate / s from previous medical aid / sAdult DEPENDANT 21 years and over Proof of registration / Affidavit of dependencyCopy of Identity Documents / copy of passportProof of adopted / Foster / Child status legal documentsPLEASE ATTACH CERTIFICATES OF MEMBERSHIP FROM THE PREVIOUS, MEDICAL SCHEME / S TO THIS APPLICATIONMember number Company code Persal number Code Race (for statistical use only)

1. CompCare Wellness Medical Scheme , hereafter referred to as “the Scheme”, confirms that your and your dependants’ personal details and medical information shall be kept

  Form, Applications, Application form, Dependants