Application form 2018 - afhealth.co.za

1 Version: SEP 2017- A Box 1101, Florida Glen, 1708 Call 0860 002 108 Fax (011) 671 5380 Email Please complete the form in full and check that all your information is correct before submitting it Please attach the following documents to this form : Government employees must attach a copy of their latest salary advice A copy of your identity document or passport A stamped bank statement or letter from your bank confi rming your banking details A copy of your payslip Copies of your previous medical aid membership certifi cates We require proof of registration for child dependants between 21 and 24 years of age who are currently note: We cannot process your Application if it is incomplete, incorrect or if you have not attached the correct documentsWould you like pre-underwriting?

2 Ye sNoSection 1: Choosing your optionPlease select one option contributions are income based. Please select the income band that applies to your gross monthly note: If you have selected BonCap you will also need to complete Section 8 and attach the required documents. If you fail to do so you will be defaulted to the highest monthly income band. BonCap: Subject to a BonCap GP and BonCap network hospital. Standard Select: Subject to nomination of a network GP and Standard Select hospital network. BonFit: Subject to a GP network and BonFit hospital network. Section 2: Intermediary detailsThis section must be completed by the broker or declare that: I am an accredited healthcare broker contracted to Bonitas Medical Fund as a fi nancial advisor.

3 I am licensed by the Financial Services Board (FSB) in terms of the Financial Advisory and Intermediary Services Act No. 37 of 2002 and accredited by the Council for Medical Schemes in terms of the Medical Schemes Act of 1998. The applicant is familiar with the information requested in the Application form and all the relevant information was provided by the applicant. The advice and assistance given to the applicant were impartial and in the best interest of the acknowledge that: The applicant has appointed me as his/her fi nancial advisor and that he/she is entitled to cancel my services at any time. I confi rm that the applicant was provided with my personal details, physical and postal address and telephone number.

4 A monthly commission of 3% of the total monthly premium plus VAT will be paid to me in terms of the Medical Schemes Act No. 131 of 1998 (or as amended). There has been no material misrepresentation of any fact by me and that in the event of material misconduct or unlawful conduct, I undertake to refund all monies paid in consequence of such misrepresentation or 3: Employee informationPlease complete this section. You must submit the completed Application form to your HR Department if your medical aid is through your employees: Please attach a current copy of your latest salary advice. Application form 2018 Broke age/agency stampName of broker/agent: Broker code:Name of brokerage:Telephone (w):Cellphone:Email:Signature of broker/agent: Date: Name of employer:Department/Division:Employee/Pe rsal number:Employment date:Medical aid start date:Number of child dependants:Number of adult dependants:BonComprehensiveBonClassicBon CompleteBonSaveBonFitStandardStandard SelectPrimaryHospital PlusHospital StandardBonEssentialBonCapR0 to R7 500R7 501 to R12 194R12 195 to R16 659R16 660+Version: SEP 2017 - A 2 Section 4.

5 Employer informationIf your medical aid is through your employer, this section must be completed by your employer and have your employer s stamp on , the Employer, confi rm that the applicant is employed by us and began employment on the employment date stated in Section 3. Contributions will be deducted according to the Scheme Rules and option chosen. Section 5: Details of main memberPlease fi ll in your details below. Ensure that all fi elds are marked clearly and can be read 6: Details of dependantsPlease enter the details for any dependants you want to be covered on your option. You may register up to four dependants on this form .

6 Please provide identity numbers or passport numbers for all dependants and attach copies of these. You must also attach copies of marriage certifi cates, birth certifi cates, adoption papers or foster care court orders where applicable. We require an affi davit for life partners. We also require copies of previous membership certifi cates with the termination date. Please note: An adult dependant is a person 21 years or older. Child rates apply to students between 21 and 24, provided that proof of registration, from a recognised tertiary institution, for the current year is attached to the 1 Employer stampName of company representative:Title of company representative:Telephone:Email:Bonitas paypoint code:Signature of employer representative: Date: Adult:Child:Relationship to main member:Title:Surname:First names:Identity number:Date of birth:Tax number:Marital status:Gender:MFCellphone:Telephone (h):Telephone (w):Email:Title:Surname:First names:Identity number:Date of birth:Tax number:Marital status:Gender:MFEthnic group.

7 BlackColouredIndianWhiteAsianOtherCellph one:Telephone (h):Telephone (w):Email:Postal address:Code:Street address:Code:Version: SEP 2017- A 3 Dependant 2 Adult:Child:Relationship to main member:Title:Surname:First names:Identity number:Date of birth:Tax number:Marital status:Gender:MFCellphone:Telephone (h):Telephone (w):Email:Dependant 3 Adult:Child:Relationship to main member:Title:Surname:First names:Identity number:Date of birth:Tax number:Marital status:Gender:MFCellphone:Telephone (h):Telephone (w):Email:Dependant 4 Adult:Child:Relationship to main member:Title:Surname:First names:Identity number:Date of birth:Tax number:Marital status:Gender:MFCellphone:Telephone (h):Telephone (w):Email:Section 7: GP nominationIf you choose the Standard Select option, you must nominate a GP from the Bonitas GP network for each benefi s namePractice numberDoctor s contact numberMain memberDependant 1 Dependant 2 Dependant 3 Dependant 4 Version: SEP 2017 - A4 Description of incomeMain memberSpouse/partnerR per monthR per monthSalary or wagesCommission and other rewardsPensions or annuitiesRental incomeTrust distributionsGovernment grantsUIF paymentsInterest on investmentsSubsidies of any kindMaintenanceOther incomeTotal incomeRRSection 8.

8 Declaration of incomePlease complete this section only if you have selected the BonCap also require the documents in the table below to be attached to this form for you and your spouse/partner. If the required documents are not submitted with this form , you will be defaulted to the highest income you We needEarn a monthly salary or salary with commissionYour latest payslip+Your bank statements for the last three months (showing the monthly income you receive)Get paid weekly/fortnightly wagesFour latest weekly payslips or two latest fortnightly payslipsORA letter from your employer/company confirming your income+Your bank statements for the last three months (showing the monthly / weekly / fortnightly income you receive)

9 Earn commission onlyProof of earningsORYour last three commission statements+Your latest IRP5+Your bank statements for the last three months (showing the monthly income you receive)Are self-employedA copy of your latest IT34A (SARS notice of assessment)+A letter from an external auditor/accounting firm confirming your income+Your bank statements for the last three months (showing the monthly income you receive)Are unemployedYour UIF statement ORA retrenchment letter or dismissal letter if you were dismissed/retrenched in the past twelve months+Your bank statements for the last three months (showing the monthly income you receive)+A letter from the person paying your contributions, confirming their relationship to you and that they are paying for your medical aidAre a minor (including children at primary and secondary school)A letter from the person paying your contributions, confirming their relationship to you and that they are paying for your medical aidVersion.

10 SEP 2017- A5If you We needAre a full-time student (tertiary education)Proof of registration from your tertiary institution (student card only will not be accepted)+A letter from the person paying your contributions, confirming their relationship to you and that they are paying for your medical aidAre a foreign studentA copy of your passport+Proof of registration from your tertiary institution+A letter from the person paying your contributions, confirming their relationship to you and that they are paying for your medical aidAre a foreign national(a person living in South Africa who is a citizen of another country)A copy of your passport+A copy of your work permit+A copy of your contract reflecting your contract period and monthly income+Your bank statements for the last three months (showing the monthly income you receive)Are temporarily disabledA copy of your IT34A (SARS notice of assessment)+A full medical report from your doctor+Your disability grant letterORA letter from the Department of Social Development+Your bank statements for the last three months (showing the monthly income you receive)Are permanently disabledA full medical report from your