Employment Transfer Form

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Section A - Employment Details (Please tick appropriate box.)
Type
- Private
- Company
Membership Number
Previous Company Name
New Company Name
New Company Address
Street Address City State / Province / Region ZIP / Postal Code Country
New CB Number
Effective Date

DD
MM
YYYY
Telephone Number
Postal Address
Street Address City State / Province / Region ZIP / Postal Code Country
Employee Number
Employment Date

DD
MM
YYYY
Designation of Employee
Salary (Applicable to Income based products)
Section B - Member Details
Title*
Initials*
Full Names*
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
Date of Birth*

DD
MM
YYYY
Age
Marital Status
- Single
- Married
- Divorced
- Widowed
- Common Law
Section C - Bank Details (For Debit Order Premiums or EFT Claim Refunds) (Attach proof of bank account details)
Effective Date

DD
MM
YYYY
Contribution Payments via Debit Order Date
- 1st of every month
- 26th of every month
Name of Account Holder
Bank Name
Bank Branch Name
Account Number
Bank Branch Code
Type of Account
- Cheque / Current
- Savings
Signature of Account Holder
Section D - Product Option Selection
Main Product*
- Elite Care
- Prestige Care
- Status Care
- Express Care
- Primary Care
- Vital Care
- Econo Care (Age Based)
- Econo Care (Income Based)
Benefit Builders (A Benefit Builder automatically terminates on the 31st December of the applicable benefit year)
Family Benefit Monthly Contribution Effective Date
Inclusive Insurance Products:
Please take note that the option selected include the following insurance benefits of which the risk is fully underwritten by a registered insurer, as required by the Medical Aid and Insurance Acts: Emergency evacuation cover, memorial transportation cover, premium protection cover and travel assistance.
Optional Insurance Products:
The following insurance benefits are not included in the options selected and is optional. The risk is fully underwritten by a registered insurer, as required by the Medical Aid and Insurance Acts.
Identification and Verification: Financial Intelligence Act, 13 of 2012 (FIA)
I hereby confirm that the information provided to me by the Policyholder, has been verified against the documentation provided and that the identity of the Policyholder has been established and verified as required in terms of Section 21 of the FIA.
Broker / Agent Name
Date

DD
MM
YYYY
Signature of Broker / Agent
Section E - Funeral Beneficiary (The beneficiary who will be paid the benefit in the event of a death.)
Name Surname I.D / Passport Number Relationship
Section F - Declaration
Members Signature
Date

DD
MM
YYYY
Section G - Documentation
The following documentation should accompany the application form as per the Financial Intelligence Act 2012 (FIA) where applicable:
Namibian Citizen
- Yes
- No
I.D / Passport of main member
Accepted file types: pdf, docx.
Proof of banking details (Please attach confirmation from the bank)
Accepted file types: pdf, docx.
Payslip for option Primary Care, Vital Care and Econo Care
Accepted file types: pdf, docx.

Employment Transfer Form

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Family Benefit	Monthly Contribution	Effective Date

Name	Surname	I.D / Passport Number	Relationship