Member Withdrawal Application Form 2018

1 Page 1 of 1 TFG Medical Aid Scheme. registration number 1578 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services WithdrawalsInitials and surnameDate of BirthParticipationstatus ReasonEffective Date Family or Dependants Please note: No backdated withdrawals allowed.

2 All withdrawals need to be submitted 3 weeks in who will receive correspondence on the Application processContact name Designation Telephone Fax Email address Preferred means of communicating (please tick one) Email c Post c Fax cContact detailsTel: 0860 123 077 PO Box 652509, Benmore 2010 TFG_11/10/17_V1_(2018)How to complete this Application form1. Please use one letter per block, complete in black ink and print To avoid administration delays, please ensure this Application is completed in full.

3 3. To be completed and returned to your Human Resources name Membership number Employee number Section B. Appeal (doctor to complete)B. Principal Member DetailsB. Principal Member DetailsPostal address Code D. Postal Address For Future CorrespondenceA. Employer Contact Details (To be completed by employer) Member Withdrawal Application form 2018 This form needs to be completed to withdraw the membership of both the dependant and the principal we areTFG Medical Aid Scheme (referred to as the Scheme ), registration number 1578.

4 This is a non-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 Medical Aid Scheme is a registered medical scheme with the Council for Medical Schemes (CMS). The CMS contact details are as follows: email / Customer Care Centre: 0861 123 267 / website