Benefit Builder Registration Form

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Section A - Member Details
Title*
Initials*
First Name*
Surname*
Physical Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Postal Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Telephone
Work Telephone
Cellphone Number*
Fax Number
Email Address
Marital Status
Date of Birth*

DD
MM
YYYY
Age
Member Number*
I.D / Passport No*
Section B - Employment Details
Employer Type*
Section C - Product Option Selection
General Rules
• We pro-rate Benefit Builders according to when you buy the options. • Benefit Builders are not available if you belong to the Primary or Vital Care options. • Benefit Builders may only be purchased once per family per annum. 80% of unused benefits in a family Benefit Builder selected by the member in the current year will be transferred in the following year to the member's Benefit Wallet as a top up medical benefit for use when needed. (Note: The balance is transferred after 4 months to allow for the run-off of medical claims incurred in the previous year.)
Benefit Builders (A Benefit Builder automatically terminates on the 31st December of the applicable benefit year)
Level Family Benefit Monthly Contribution Effective Date
Section D - Documentation
Document Type
Add Doc
Accepted file types: pdf, docx.
Section E - Declaration by Principal Member
I, the undersigned, understand that the Benefit Builders are pro-rated for the period from the effective date up to 31 December 2017. I further declare that the information submitted is true and correct.
Signed at*
on this*

DD
MM
YYYY
day of*
Print Applicant Name*
Principal Member Signature

Benefit Builder Registration Form

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Level	Family Benefit	Monthly Contribution	Effective Date