Transcription of application to add dependants with underwriting
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Example: tourism industry
application to add dependants with underwriting
Page 1 of 11LA Health Medical Scheme, registration number 1145, is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services detailsTel: 0860 103 933 PO Box 652509, Benmore 2010 to add dependants (with underwriting )Complete this form if you want to add dependant/s to your membership of LA Health Medical we areLA Health Medical Scheme (referred to as the Scheme ), registration number 1145, is the medical scheme that you are applying to become a member of. This is a not-for-profit organisation, registered with the Council for Medical Health (Pty) Ltd (referred to as the administrator ) is a separate company and an authorised financial services provider (registration number 1997/013480/07). We take care of the administration of your membership for the to complete the form1.
application form 6LJQDWXUH RI SDUWQHU Please do not sign an incomplete application form 'DWH 'DWH 4. About your dependant/s (only complete if applying for cover) Dependant 1 7LWOH ,QLWLDOV 6XUQDPH )LUVW QDPH V DV SHU LGHQWLW\ GRFXPHQW 3UHIHUUHG QDPH 6H[ 'DWH RI ELUWK ,' RU SDVVSRUW QXPEHU &RXQWU\ RI LVVXH
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