Organisation Application Amendment Form

Section A: Broker or Agent details: This section must be completed by the broker or agent

Name of Broker/Agent

Broker/Agent Code:

Name of Brokerage

Telephone (W)

Cellphone *

Email *

Section B : Organisation details

Name of Organisation *

Registration Number

BP Number

Business Physical Address *

Business Postal Address (if applicable)

Industry *

Nature of Business

Telephone (W)

Fax Number

Medical Fund Start Date *

Contribution Due Date

Previously Registered on the Fund(If Yes, Please provide us with the group number)

Group Number

HR Contact Person

Title *

Surname *

First Name/s *

Telephone (W) *

Fax Number

Cellphone

Email

Finance Contact Person

Title *

Surname *

First Name/s *

Telephone (W) *

Fax Number

Cellphone

Email

Section C: Banking details for refunds

Proof of banking details required in the form of letter from bank or banking details on company letterhead signed and stamped by the relevant issuer

Bank Name *

Branch Name *

Branch Code *

Account Type *

Account Number *

Account Holder (Company) *

Authorised Personnel

Job Title

Section D: Company’s previous medical fund information

Name of Fund

Date Joined

Termination Date

Section E: Your Employee Base

Total Employees

Number of employees that Generation Health Fund will cover

Section F

Employer specific requirements/conditions

Organisation Application Amendment Form