Addition of dependants

1 1 of 7ID/Passport no. nnnnnnnnnnnnn InitialSection A: Main member detailsnnnInitialsnnnnnnnnnnMembership nonnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn SurnameAddition of dependantsformNo beneficiary may be enrolled with different medical schemes simultaneouslySection B1: Details of dependantsDependant 1 First name nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnSurname nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnID/Passp ort no. nnnnnnnnnnnnnn Gender n M n FCountry in which passport was issued nnnnnnnnnnnnnnnnnnnnnnnnDate of birth nnnnnnnnD D M MY Y Y Y Mobile no. nnnnnnnnnnnEmail address nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnRelation ship with main member nnnnnnnnnnnnnnnnnnnnnnnnnnIs the dependant factually dependent on main member? n Ye s n No Has the dependant ever been a main member or dependant of GEMS? n Ye s n No If Yes, provide membership no.

2 NnnnnnnnnnIs the dependant currently a member or a dependant of another medical scheme? n Ye s n No If Yes, have you given notice of termination to the current medical scheme? n Yes* n No** If Yes, please attach a certificate of membership from that medical scheme reflecting the end date of the membership and any waiting periods that were applied. We cannot finalise your application without this.** If No, please give the required notice to the current medical scheme before submitting the application, and attach a certificate of membership from that medical scheme indicating the end date of the membership and any waiting period that were applied. We cannot finalise your application without 2 First name nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnSurname nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnID/Passp ort no. nnnnnnnnnnnnnn Gender n M n FCountry in which passport was issued nnnnnnnnnnnnnnnnnnnnnnnnDate of birth nnnnnnnnD D M MY Y Y Y Mobile no.

3 NnnnnnnnnnnEmail address nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnRelation ship with main member nnnnnnnnnnnnnnnnnnnnnnnnnnIs the dependant factually dependent on main member? n Ye s n No Has the dependant ever been a main member or dependant of GEMS? n Ye s n No If Yes, provide membership no. nnnnnnnnnnIs the dependant currently a member or a dependant of another medical scheme? n Ye s n No If Yes, have you given notice of termination to the current medical scheme? n Yes* n No** If Yes, please attach a certificate of membership from that medical scheme reflecting the end date of the membership and any waiting periods that were applied. We cannot finalise your application without this.** If No, please give the required notice to the current medical scheme before submitting the application, and attach a certificate of membership from that medical scheme indicating the end date of the membership and any waiting period that were applied.

4 We cannot finalise your application without that all applicable sections are completed in full, and that you provide all necessary supplementary documentation. Submit the completed form to GEMS via any of the following channels: 0861 00 4367 GEMS, Private Bag X782, Cape Town 8000 2 of 7ID/Passport no. nnnnnnnnnnnnn InitialProvide the details of all the medical schemes that your dependants previously belonged to, if nameScheme nameStart dateIs the dependant still a member?End date if already resignedReason for leaving Yes No Yes No Yes No Yes No nnnnnnnnPlease ensure that you enclose the following with your application form: Copy of relevant ID. An affidavit confirming relationship if surnames are different. Legal documentation if child is adopted. An affidavit confirming factual dependency if partners are co-habiting, including witnesses.

5 Proof of registration at a legally recognised tertiary institution (student card does not serve as proof), if dependant is over 21. Please note that you will have to pay the adult rate if this report is not enclosed with your application form. Medical report confirming disability for a dependant over 21. Please note that you will have to pay the adult rate if this report is not enclosed with your application B2: Medical history and general health informationFailure to disclose pre-existing conditions could limit and/or exclude certain benefits or result in termination of your you are not obliged to disclose the HIV status of your dependant(s) on this form, you are required, in line with the Scheme rules and underwriting criteria, to contact our confidential HIV line on 0860 436 736 within seven working days from the date that you submit your membership application to GEMS, should you be receiving HIV-related treatment.

6 We want to assure you that we treat this information with the strictest of medical advice, diagnosis, treatment or care received or recommended in respect of any of your dependants (excluding newborns and/or newly-adopted children) as per this application form, in respect of any of the following, in the last 12 months? (Please supply the required information by marking the relevant box with a X.) any of your dependants use chronic medicine? or problems with the heart or cardiovascular system, heart murmur, high blood pressure, high cholesterol, shortness of breath, palpitations, chest pain, angina, heart attack and/or any other cardiac or blood or lung disorders, tuberculosis, asthma, persistent cough or other breathing problems, emphysema, coughing up blood, cystic fibrosis, sinusitis or allergic of the digestive system, stomach, gall bladder, pancreas or liver, gastric or duodenal ulcer, heartburn, hiatus hernia, rectal bleeding, Crohn s disease, ulcerative colitis, irritable bowel syndrome, hepatitis, cirrhosis, liver failure or have you ever had a gastroscopy or colonoscopy?

7 Or disorders of the kidneys, bladder or reproductive organs, abnormal urine tests, kidney stones, nephritis, prostatitis, bladder infections or sexually transmitted of the nervous system or brain, epilepsy, stroke, multiple sclerosis, migraine, headaches, paralysis, Parkinson s disease or have you or any of your dependants been advised to have a MRI or CT scan?YESNO3 of 7ID/Passport no. nnnnnnnnnnnnn disorders, depression, anxiety, panic attacks, schizophrenia, eating disorders, attention deficit hyperkinetic disorder (ADHD) or post-traumatic stress , nose, throat or eye disorders, defective vision, cataracts, glaucoma, retinitis, disorders of the cornea, hearing loss, ear discharge, otitis media or or diseases of the skin, muscles, bones, joints, limbs or spine, any skin rash, arthritis, gout, fibromyalgia, any back/neck/hip/knee or other joint trouble, multiple sclerosis, any joint problems or replacements, acne, eczema or psoriasis?

8 , sugar in urine, thyroid or other glandular or blood disorders, anaemia, bleeding disorders, growth disorder, Cushing s disease or Addison s , a growth or tumour of any kind including moles removed (malignant/benign). any of your dependants currently undergoing or anticipating any specialised dental/maxillofacial treatment?YESNO13. Have any of your dependants had any accidents (including motor vehicle accidents)? any of your dependants taking ongoing medicine for any condition not listed in any other question? any of your dependants had any surgical procedure? any of your dependants awaiting or planning any operation or admission to any hospital in the next 12 months? there any other condition or symptom, which is not detailed in any other question, for which medical advice, diagnosis, care or treatment has already been recommended or received, or could potentially result in a medical claim within the next 12 months?

9 Disorders, abnormal pap smear or mammogram, endometriosis, ovarian cysts, fibroids, infertility, disorders of the cervix, menstrual disorders or any abnormality of pregnancy or any of your dependants pregnant? If so, what is the expected date of delivery?Date:YESNO4 of 7ID/Passport no. nnnnnnnnnnnnn InitialIf your answer was Yes to any of the above questions, please provide full particulars in the space below. Please use a separate sheet of paper if the space is not B3: Acknowledgment of waiting periodsPlease note: GEMS will impose underwriting on certain membership categories in the form of waiting periods. Please declare your acceptance of this by signing below. I am aware that GEMS reserves the right to impose waiting periods on any beneficiary (myself or any of my dependants ). GEMS will notify me in writing should any of these waiting periods apply to me and/or any of my registered dependants , based on the information provided in this application.

10 I understand that a three-month general and/or twelve-month condition-specific waiting period may be imposed on the following membership categories: Main members who resign from GEMS with their dependants (without also resigning from the Public Service) and then re-join GEMS at a later stage. dependants who are resigned from GEMS and who are then re-registered by the main member at a later stage. dependants who join GEMS on a different date from the main member (excluding newborn babies and newly-adopted children).Signature of main membernnnnnnnnD D M MY Y Y YDateI, ID number nnnnnnnnnnnnn Section C: DeclarationSignature of main membernnnnnnnnD D M MY Y Y YDatedeclare that the information submitted is true and of person suffering from illnessQuestion numberIllness or conditionDate on which illness beganDate of last occuranceName of treating doctorDoctor s contact detailsTreatment recommended (medicine, etc.)