Member Record Amendment Form

Section A: Principal Membership Details (must be completed)

Title *

Surname *

First Name/s *

Membership Number *

Section B: Confirmation or Change of Address / Contact Details

Telephone (H)

Telephone (W)

Fax Number

Cellphone *

Email *

Physical Address *

Postal Address

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

GenSave Plan(No MSA Option)

Green Plan (No MSA Option)

Jade Plan (No MSA Option)

Ebony Plan

Ivory Plan

Mahogany

Section D: Change of Personal Details

Title

Surname

First Name/s

ID Number

Passport Number (Foreign national)

Date of Birth

Gender

Marital Status

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

Bank Name

Branch Name

Branch Code

Account Type

Account Number

Account Holder

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

Name of Employer

Department/Division

Employee Number

Employment Start Date

Medical Scheme Start Date

Section G: Employer:

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

Employer Representative

Position Held

Telephone (W)

Cellphone

Group Number

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

Section H

First Name/s

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 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 K

Full Name As Reflected On Your Membership Card

Relationship To Principal Member

Date Joined

Termination Date