Organisation Application Ammendment Form

1 Start 2 Complete

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: *

Month

Day

Year

Contribution Due Date:

Month

Day

Year

Previously Registered on the Fund:

(If Yes, Please provide us with the group number)

Group Number:

HR Contact Person

Title: *

Surname: *

Name: *

Telephone (w): *

Fax number:

Cellphone:

E-mail:

Finance Contact person

Title: *

Surname: *

Name: *

Telephone (w): *

Fax number:

E-mail:

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:

Month

Day

Year

Termination Date:

Month

Day

Year

Section E: Your Employee Base

Total Employees:

Number of employees that Generation Health Fund will cover:

Section F

Employer specific requirements/conditions:

Organisation Application Ammendment Form

Organisation Application Ammendment Form

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

Section B : Organisation details

HR Contact Person

Finance Contact person

Section C: Banking details for refunds

Section D: Company’s previous medical fund information

Section E: Your Employee Base

Section F

Our Plans

Zones

About Us

Contact Us

Organisation Application Ammendment Form

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Organisation Application Ammendment Form

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

Section B : Organisation details

HR Contact Person

Finance Contact person

Section C: Banking details for refunds

Section D: Company’s previous medical fund information

Section E: Your Employee Base

Section F