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Member Zone

Member Record Amendment Form

Section A: Principal Membership Details (must be completed)

Section B: Confirmation or Change of Address / Contact Details

Section C: Change of Plan or Savings Level (Beneficiary)

Section D: Change of Personal Details

Section E: Change of Bank Details of Principal Member

For refund of claim/s, savings payments, please provide the following documents:
  • If account holder differs from that of principal member, a letter from the account holder is required approving the loading of the bank account details
  • Copy of the bank statement / cancelled cheque / letter from the bank / bank letterhead confirming the account holder’s details

Section F: Change of Employment Details

Please complete this section. You must submit the completed application form to your HR department if
your medical aid is through the employer

Section G: Employer:

If your medical aid is through the employer this section must be completed and stamped by your employer

Section H: Registration of Spouse / Partner / Newborn / Additional Adult or Child Dependent

Section H:
Name:Surname:Gender:Date of Birth:Identity Number:Relationship:Plan:

Section I: Medical Details

Please enter the medical history of your dependants below. Failure to disclose medical conditions could limit your benefits,
exclude you from receiving some benefits or result in termination of your membership.
Section I
Condition/Illness:Name/s:Date of Last Treatment:

Section J: Previous Medical Scheme Information

Please provide full details of the previous membership and attach a copy of previous certificate of
membership reflecting the termination date
Section J:
Member Name:Scheme:Member Number:Join Date:Termination Date:

Section K: Termination of Dependent Membership

Section K:
Full Name/s as Reflected on Your Fund Membership Card:Relationship to Principal Member:Date Joined:Termination Date:

Biller Code: 35376                           

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