KORPORATIEWE AANSOEKVORM (Verkorte weergawe) - Bestmed
KORPORATIEWE AANSOEKVORM (Verkorte weergawe) - Bestmed
KORPORATIEWE AANSOEKVORM (Verkorte weergawe) - Bestmed
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CORPORATE APPLICATION FORM (Shortened version)<br />
<strong>KORPORATIEWE</strong> <strong>AANSOEKVORM</strong> (<strong>Verkorte</strong> <strong>weergawe</strong>)<br />
FOR OFFICE USE ONLY / SLEGS VIR KANTOORGEBRUIK<br />
Membership number<br />
Lidmaatskapnommer<br />
Health advisor code<br />
Kode van Gesondheidsorg adviseur<br />
Residential address<br />
Residensiële adres<br />
Organisation number<br />
Organisasienommer<br />
1. APPLICANT (PRINCIPAL MEMBER) / AANSOEKER (HOOFLID)<br />
Postal code<br />
Poskode<br />
• Block A, Glenfield Office Park, 361 Oberon Avenue, Faerie Glen, Pretoria, 0081, RSA • PO Box 2297, Pretoria, 0001, RSA<br />
• Client service 086 000 2378 • Fax +27 (0)12 472 6500 • E-mail service@bestmed.co.za • www.bestmed.co.za • Reg no. 1252<br />
<strong>Bestmed</strong> Medical Scheme is an Authorised Financial Services Provider (FSP no. 44058)<br />
Corporate Application Form (Shortened)/V3/2013/03/19/703490 1 of 4<br />
Start date<br />
Aanvangsdatum<br />
Applicant to complete sections 1-5. HR practitioner to complete section 6. Complete in block letters.<br />
Afdelings 1-5 moet deur die aansoeker voltooi word. Werkgewer moet afdeling 6 voltooi. Voltooi in blokletters.<br />
Title Surname<br />
Titel Van<br />
Fax<br />
Faks<br />
E-mail<br />
E-pos<br />
Contribution<br />
Ledegeld<br />
Full names<br />
Volle name<br />
Date of birth of member<br />
D D M M Y Y Y Y<br />
Geboortedatum van lid<br />
Language preference<br />
Taalvoorkeur<br />
Eng Afr<br />
Marital status Date of marriage/divorce<br />
D D M M Y Y Y<br />
Huwelikstatus Datum van huwelik/egskeiding<br />
Y<br />
ID number Gender<br />
ID nommer Geslag<br />
(Need copy of ID/Passport / Benodig afskrif van ID/Paspoort)<br />
M F<br />
2. ADDRESS AND CONTACT DETAILS (PRINCIPAL MEMBER) / ADRES EN KONTAKBESONDERHEDE (HOOFLID)<br />
Medical correspondence to be sent to<br />
Stuur mediese korrespondensie na<br />
Postal code<br />
Poskode<br />
Deliver starter pack via courier to (Physical address)<br />
Lewer beginpak af via koerier by (Fisiese adres)<br />
3. DEPENDANTS / AFHANKLIKES<br />
Name<br />
Naam<br />
*Declare other/Verklaar ander<br />
Surname<br />
(If different from principal member)<br />
Van (Indien verskillend van hooflid)<br />
Gender<br />
Geslag<br />
M<br />
M<br />
M<br />
M<br />
M<br />
M<br />
F<br />
F<br />
F<br />
F<br />
F<br />
F<br />
ID number<br />
ID nommer<br />
Tel (w)<br />
Tel (h)<br />
Cell<br />
Sel<br />
Total member cards<br />
Aantal lidkaarte<br />
Relationship<br />
Verwantskap<br />
“Other” is defined as a parent, brother or sister of a member for whom the member is de facto liable for family care and support, and for whom contributions as for adult dependants are<br />
payable, if older than 21 years.<br />
“Ander” word omskryf as ‘n ouer, broer of suster van ‘n lid vir die de facto aanspreeklik is vir gesinsorg en onderhoud, en vir wie ledegeld vir volwasse afhanklikes betaalbaar is, indien<br />
ouer as 21 jaar.<br />
Children are regarded as such only up to the age of 21, unless studying (but not older than 26) or dependent on the member due to a mental or physical disability.<br />
Tot op die ouderdom van 21, word kinders as minderjarig geag, tensy die kind studeer (nie ouer as 26 nie) of as gevolg van fisiese of verstandelike gestremdheid, afhanklik is van die hooflid.<br />
703490 App Form CORP Members Short version.indd 1 2013/03/20 12:53 PM<br />
Spouse<br />
Gade<br />
Spouse<br />
Gade<br />
Spouse<br />
Gade<br />
Partner<br />
Metgesel<br />
Partner<br />
Metgesel<br />
Partner<br />
Metgesel<br />
Child<br />
Kind<br />
Child<br />
Kind<br />
Child<br />
Kind<br />
Other<br />
Ander<br />
Other<br />
Ander<br />
Other<br />
Ander
4. 4. THE SELECT FOLLOwING BENEFIT DOCUMENTS OPTION / GESELEKTEERDE ARE COMPULSORY VOORDEELOPSIE<br />
/ DIE VOLGENDE DOKUMENTE IS ‘N VEREISTE<br />
• A copy of the ID or passport of the principal member and/or<br />
dependant(s)<br />
• If a child is older than 21 - proof of full time registration at a<br />
tertiary institution (up to the age of 26)<br />
• Extended family - declaration of dependant(s)<br />
• Certificate(s) of previous membership at another medical scheme<br />
• Please note that all applicants must provide proof of previous<br />
medical scheme membership (this applies to members or all dependants)<br />
• Please provide proof of address such as a utility bill<br />
5. CLAIM REIMBURSEMENT DETAILS / EIS BETALINGS BESONDERHEDE<br />
Account holder<br />
Rekeninghouer<br />
Bank<br />
Branch name and town<br />
Taknaam en dorp<br />
Account number<br />
Rekeningnommer<br />
Type of account<br />
Tipe rekening<br />
Cheque / Tjek Savings / Spaar<br />
Corporate Application Form (Shortened)/V3/2013/03/19/703490 2 of 4<br />
Branch number<br />
Taknommer<br />
Title Surname<br />
Titel ___________________________________________________________________ Van _____________________________________________________<br />
Full names<br />
Volle name ___________________________________________________________________________________________________________________________<br />
ID number<br />
ID nommer<br />
Signature of applicant Signature of witness<br />
Handtekening van aansoeker Handtekening van getuie<br />
Note: Copy of a bank statement to be attached.<br />
Nota: Afskrif van ´n bankstaat moet aangeheg word.<br />
I would like to receive <strong>Bestmed</strong> marketing material/Ek wil graag <strong>Bestmed</strong> bemarkingsmateriaal ontvang<br />
D D M M Y Y Y Y<br />
6. STATEMENT BY EMPLOYER TO APPLICANT / VERKLARING DEUR wERKGEwER AANGAANDE AANSOEKER<br />
To be completed by Employer / Moet deur Werkgewer voltooi word<br />
Employer name Employer code<br />
Naam van Werkgewer Werkgewerkode<br />
Name of HR practitioner _<br />
Naam van Menslikehulpbronne-praktisyn<br />
e. Personnel number / Personeelnommer<br />
Contact number<br />
Telefoon nommer<br />
State that the applicant/Verklaar dat die aansoeker:<br />
a. Has been permanently employed by us since/In ons diens is vanaf<br />
D D M M Y Y Y Y<br />
*Compulsory field<br />
Verpligte veld<br />
b. Start date/Aanvangsdatum D D M M Y Y Y Y<br />
*Compulsory field<br />
Verpligte veld<br />
*Compulsory field<br />
c. Salary per annum/Jaarlikse salaris R<br />
Verpligte veld<br />
d. Department / Departement<br />
Administrative / Administratief Academic / Akademies<br />
f. Total monthly contribution to be paid to <strong>Bestmed</strong>/Totale maandelikse ledegeld betaalbaar aan <strong>Bestmed</strong> ( R )<br />
g. Option choice (See overleaf)<br />
• ‘n Kopie van die ID of paspoort van die hooflid en/of afhanklike(s)<br />
• As ‘n kind ouer as 21 is - bewys van voltydse registrasie by ‘n<br />
tersiêre instelling (tot op ‘n ouderdom van 26)<br />
• Addisionele familie - verklaring van afhanklike(s)<br />
• Sertifikaat(e) van vorige lidmaatskap by ‘n ander mediese skema<br />
• Neem asseblief kennis daarvan dat alle aansoekers bewys van<br />
lidmaatskap van vorige mediese skemas moet voorsien (Dit geld vir<br />
lede sowel as alle afhanklikes)<br />
• Verskaf asseblief bewys van resedensiëlle adress soos ‘n<br />
munisipaleteits rekening<br />
Yes / Ja No / Nee<br />
I would like to receive Top Living, <strong>Bestmed</strong>’s electronic magazine/Ek wil graag Top Living, <strong>Bestmed</strong> se elektroniese tydskrif ontvang<br />
Yes / Ja No / Nee<br />
703490 App Form CORP Members Short version.indd 2 2013/03/20 12:53 PM
Benefit option<br />
Voordeelopsie<br />
Beat1 ♥<br />
Beat2 ♥<br />
Beat3 ♥<br />
* If Pulse1, please indicate the following / Indien Pulse1 dui asseblief die volgende aan:<br />
Provider’s name<br />
Verskaffersnaam<br />
Practice number<br />
Praktyknommer<br />
GP Choice<br />
Algemene Praktisyn Keuse<br />
Name of<br />
Naam van<br />
Principal Applicant<br />
Hoof Aansoeker<br />
Dependant<br />
Afhanklike<br />
Dependant<br />
Afhanklike<br />
Dependant<br />
Afhanklike<br />
Dependant<br />
Afhanklike<br />
Dependant<br />
Afhanklike<br />
Human Resources practitioner/Menslike Hulpbron-praktisyn<br />
Benefit option<br />
Voordeelopsie<br />
Pace1 ♥<br />
Pace2 ♥<br />
Pace3 ♥<br />
Signature of Health Advisor/Handtekening van Gesondheidsorg-adviseur<br />
PLEASE NOTE / NEEM ASSEBLIEF KENNIS<br />
Chronic medicine benefit / Chroniese medisyne-voordeel<br />
Corporate Application Form (Shortened)/V3/2013/03/19/703490 3 of 4<br />
GP<br />
Algemene Praktisyn<br />
Telephone number/Telefoonnommer<br />
Benefit option<br />
Voordeelopsie<br />
Pace4 ♥<br />
Pulse1 ♥<br />
Pulse2 ♥<br />
*<br />
Practice number<br />
Praktyknommer<br />
To gain access to the chronic medicine benefit, it is compulsory to apply for benefits by completing and submitting a separate chronic medicine<br />
application form. This application form is available on the <strong>Bestmed</strong> website at www.bestmed.co.za or alternatively, please contact 086 000 2378 for the<br />
form or related queries.<br />
Om toegang tot die chroniese medisyne-voordeel te verkry, moet lede aansoek doen deur die voltooiing en inhandiging van ‘n afsonderlike chroniese<br />
medisyne aansoekvorm. Hierdie vorm is beskikbaar op die <strong>Bestmed</strong>-webtuiste by www.bestmed.co.za of skakel 086 000 2378 vir die vorm of verwante<br />
navrae.<br />
HIV and Oncology / MIV en Onkologie<br />
To gain access to the Oncology or the HIV benefits, it is compulsory to apply for benefits by completing and submitting the relevant application form.<br />
The application forms are available on the <strong>Bestmed</strong> website at www.bestmed.co.za or alternatively, please contact us on the numbers below for the<br />
forms or related queries:<br />
Om toegang tot die Onkologie of die MIV-voordele te kry, is dit nodig om aansoek te doen vir voordele deur die voltooiing en inhandiging van die<br />
betrokke aansoekvorm.<br />
Die vorms is beskikbaar op die <strong>Bestmed</strong>-webtuiste by www.bestmed.co.za of kontak ons op die nommers hieronder vir die vorms of verwante navrae:<br />
HIV programme / MIV-program: (011) 251 9400<br />
Oncology programme / Onkologie-program: (012) 472 6254<br />
703490 App Form CORP Members Short version.indd 3 2013/03/20 12:53 PM
HEALTHCARE ADVISOR DECLARATION / GESONDHEIDSORG-ADVISEUR SE VERKLARING<br />
1) I declare that I am an accredited <strong>Bestmed</strong> Financial Advisor, I am fully licensed by the Financial Services Board (FSB) in terms of the Financial<br />
Advisory and Intermediary Services Act 37 of 2002.<br />
2) I accept that the applicant has appointed me as his/her financial advisor and that he/she is entitled to cancel my services at his/her will.<br />
3) I confirm that the applicant was given my personal details including my physical and postal address and contact number.<br />
4) I acknowledge that in terms of Act 131 of 1998 in the Medical Schemes Act (or as amended), a monthly commission of 3% from the total premium<br />
up to a maximum of R65.65 will paid out to me.<br />
5) I acknowledge that there has been no physical misrepresentation of any fact by me and that in the event of material or unlawful conduct,<br />
I will be responsible for refunding all monies paid in effect of such misrepresentation or conduct.<br />
6) The applicant is familiar with the information required in the application form and he/she has provided all the correct information.<br />
7) The advice and support given to the applicant was unbiased and in his/her best interest.<br />
8) The applicant has personally signed this application form.<br />
1) Ek verklaar dat ek ’n geakkrediteerde <strong>Bestmed</strong> Finansiële Adviseur is, ek is ten volle gelisensiëer deur die Raad op Finansiële Dienste (RFD) in<br />
terme van die Wet op Finansiële Advies-en Tussengangerdienste, Wet 37 van 2002.<br />
2) Ek aanvaar dat die aansoeker my aangestel het as sy/haar finansiële adviseur en dat hy/sy geregtig is om my dienste te kanselleer.<br />
3) Ek bevestig dat die aansoeker my persoonlike besonderhede, insluitend my fisiese en posadres sowel as my telefoonnommer ontvang het.<br />
4) Ek erken dat in terme van Wet 131 van 1998 van die Wet op Mediese Skemas (of soos gewysig), ’n maandelikse kommissie van 3% van die totale<br />
premie tot ’n maksimum van R65.65 aan my uitbetaal sal word.<br />
5) Ek erken dat daar geen fisiese wanvoorstelling van enige feite deur my is nie en dat in die geval van materiële of onwettige optrede, ek<br />
verantwoordelik sal wees vir die terugbetaling van alle gelde wat betaal is in die effek van so ’n wanvoorstelling.<br />
6) Die aansoeker is bekend met die inligting wat benodig word in die aansoekvorm en hy/sy het al die korrekte inligting verskaf.<br />
7) Die raad en ondersteuning wat gegee was aan die aansoeker is onbevooroordeeld en in sy/haar beste belang.<br />
8) Die aansoeker het persoonlik hierdie aansoekvorm onderteken.<br />
Healthcare Advisor name or details/Gesondheidsorg-adviseur naam of besonderhede Healthcare Advisor Code/Gesondheidsorg-adviseur Kode<br />
Signature of Healthcare Advisor/Handtekening van Gesondheidsorg-adviseur<br />
Corporate Application Form (Shortened)/V3/2013/03/19/703490 4 of 4<br />
Date<br />
Datum<br />
D D M M Y Y Y Y<br />
703490 App Form CORP Members Short version.indd 4 2013/03/20 12:53 PM
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