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About
Our Plans
Products
Waiting Periods
Forms/ Zones
Broker Zone
Member Zone
Service Provider Zone
News and Insights
Make Payment
Contact
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
*
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11
12
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31
Select Year
2125
2124
2123
2122
2121
2120
2119
2118
2117
2116
2115
2114
2113
2112
2111
2110
2109
2108
2107
2106
2105
2104
2103
2102
2101
2100
2099
2098
2097
2096
2095
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2093
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2020
2019
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2017
2016
2015
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2012
2011
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2009
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2002
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1991
1990
1989
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1982
1981
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1978
1977
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1975
1974
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1972
1971
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1963
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1961
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1952
1951
1950
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1948
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1946
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1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
Contribution Due Date
Select month
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Select day
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11
12
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14
15
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20
21
22
23
24
25
26
27
28
29
30
31
Select Year
2125
2124
2123
2122
2121
2120
2119
2118
2117
2116
2115
2114
2113
2112
2111
2110
2109
2108
2107
2106
2105
2104
2103
2102
2101
2100
2099
2098
2097
2096
2095
2094
2093
2092
2091
2090
2089
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2086
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2029
2028
2027
2026
2025
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2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
Previously Registered on the Fund
- Select -
Yes
No
(If Yes, Please provide us with the group number)
Group Number
HR Contact Person
Title
*
- Select -
Mr
Mrs
Ms
Miss
Dr
Prof
Sir
Fr
Sr
Eng
Sgt
Bishop
Honourable
Rev
Pastor
Surname
*
First Name/s
*
Telephone (W)
*
Fax Number
Cellphone
Email
Finance Contact Person
Title
*
- Select -
Mr
Mrs
Ms
Miss
Dr
Prof
Sir
Fr
Sr
Eng
Sgt
Bishop
Honourable
Rev
Pastor
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
Select month
1
2
3
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5
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9
10
11
12
Select day
1
2
3
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5
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Select Year
2125
2124
2123
2122
2121
2120
2119
2118
2117
2116
2115
2114
2113
2112
2111
2110
2109
2108
2107
2106
2105
2104
2103
2102
2101
2100
2099
2098
2097
2096
2095
2094
2093
2092
2091
2090
2089
2088
2087
2086
2085
2084
2083
2082
2081
2080
2079
2078
2077
2076
2075
2074
2073
2072
2071
2070
2069
2068
2067
2066
2065
2064
2063
2062
2061
2060
2059
2058
2057
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2054
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2052
2051
2050
2049
2048
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2046
2045
2044
2043
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
Termination Date
Select month
1
2
3
4
5
6
7
8
9
10
11
12
Select day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Select Year
2125
2124
2123
2122
2121
2120
2119
2118
2117
2116
2115
2114
2113
2112
2111
2110
2109
2108
2107
2106
2105
2104
2103
2102
2101
2100
2099
2098
2097
2096
2095
2094
2093
2092
2091
2090
2089
2088
2087
2086
2085
2084
2083
2082
2081
2080
2079
2078
2077
2076
2075
2074
2073
2072
2071
2070
2069
2068
2067
2066
2065
2064
2063
2062
2061
2060
2059
2058
2057
2056
2055
2054
2053
2052
2051
2050
2049
2048
2047
2046
2045
2044
2043
2042
2041
2040
2039
2038
2037
2036
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
Section E: Your Employee Base
Total Employees
Number of employees that Generation Health Fund will cover
Section F
Employer specific requirements/conditions
Submit
