TERMINATION OR TRANSFER ADVICE - Sizwe

CODE EFFECTIVE DATE _____ NAME AND INITIALS _____MEMBER S MEDICAL AID NUMBER PAYROLL NUMBER FORWARDING ADDRESS OR COMPANY TO WHICH EMPLOYEE TRANSFERRED_____ CODE EFFECTIVE DATE _____ NAME AND INITIALS _____MEMBER S MEDICAL AID NUMBER PAYROLL NUMBER FORWARDING ADDRESS OR COMPANY TO WHICH EMPLOYEE TRANSFERRED_____ CODE EFFECTIVE DATE _____ NAME AND INITIALS _____MEMBER S MEDICAL AID NUMBER PAYROLL NUMBER FORWARDING ADDRESS OR COMPANY TO WHICH EMPLOYEE TRANSFERRED_____ CODE EFFECTIVE DATE _____ NAME AND INITIALS _____MEMBER S MEDICAL AID NUMBER PAYROLL NUMBER FORWARDING ADDRESS OR COMPANY TO WHICH EMPLOYEE TRANSFERRED_____TERMINATION OR TRANSFER ADVICESECTION 1 TERMINATION OR TRANSFER OF MEMBERSHIPSECTION 2 DECLARATION BY EMPLOYERDISTRIBUTION OF ADVICE ORIGINAL TO Sizwe MEDICAL FUND COPY TO BE RETAINED BY COMPANYPAYPOINT NUMBER/CODE _____We confir m that the inf or mation is tr ue and correct and that the relevant contribution adjustments will be ef fected on the appropriat e contribution _____ DESIGNATION _____DATE _____ E-MAIL ADDRESS _____Pl

code effective date _____ name and initials_____ member’s medical aid number payroll number

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