Membership Application Form - Renaissance Health Medical Aid Fund

Membership Application

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Office Use Only
Intermediary Information (Broker Number)
Processed by
Date

DD
MM
YYYY
Exclusion(s)
Exclusions Approved By
Section A - 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
Marital Status
Date of Birth*

DD
MM
YYYY
Age
Proposed Joining Date*

DD
MM
YYYY
I.D / Passport No*
Section B - Employment Details
Employer Type*
CB Number
Company Name
Nature of Industry
Company Physical Address
Street Address City State / Province / Region ZIP / Postal Code Country
Company Postal Address
Street Address City State / Province / Region ZIP / Postal Code Country
Telephone Number
Employee Number
Employment Date

DD
MM
YYYY
Designation of Employee
Section C - Bank Details
Name of Account Holder*
Type of Account*
Use This Account For*
Debit Order Date*

DD
MM
YYYY
Bank Name*
Branch Name*
Account Number*
Branch Code*
Signature of Account Holder
Section D - Beneficiaries to be Covered
Beneficiaries
I.D / Passport No. First Name Surname Relationship Gender Disabled Date of Birth
Section E - 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
Level 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.
Inclusive Insurance Products
- Funeral Plan
- Complimed Plus
- Combo (Funeral Cover / Complimed Plus / Hospicash)
Section F - Previous Medical Membership
Name of previous Medical Aid Fund
Membership Number
Date Joined

DD
MM
YYYY
Date Resigned

DD
MM
YYYY
Spouse Previous Medical Membeship
Name of previous Medical Aid Fund
Membership Number
Date Joined

DD
MM
YYYY
Date Resigned

DD
MM
YYYY
Section G - Medical History
Supply full details on questions below. Where an answer to a question is “yes”, please provide details in the space provided below. Questions pertain to Applicant and ALL BENEFICIARIES.
Non-disclosure of information may result in termination of membership or non-payment of some medical treatment. Have you / your spouse or any one of your beneficiaries ever experienced any of the following?
Chest pain/angina, heart attack, heart failure, heart valve disease, rheumatic fever, high blood pressure, (hypertension), high cholesterol, heart murmurs, circulatory problems/disorders, varicose veins, deep vein thrombosis(DVT), or any other heart or circulatory problems.
- Yes
- No
Asthma, difficulty with breathing, bronchospasm, turbeculosis(TB), coughing up blood, emphysema, pneumonia, cystic fibrosis, chronic bronchitis, shortness of breath, any other breathing problems. Smoking.
- Yes
- No
Blood in urine, kidney failure, polycystic kidneys, kidney or bladder infections, removal of kidney(nephretomy), kidney stones, abnormal kidney or urine tests or any other kidney problems.
- Yes
- No
Endometriosis, infertility, ovaria cysts, hysterectomy, abnormal PAP smear, laser treatment, cervix and breast biopsies, fibroadenosis of the breast, laparoscopies, hormone replacement therapy, prostate infections or surgery, prostate enlargement or any other reproductive problems.
- Yes
- No
Duodenal ulcers, gastric ulcers, peptic ulcers, hiatus hernia, colon problems, crohn’s disease, ulcerative clitis, gall bladder problems, liver problems or any other digestive problems. Obesity.
- Yes
- No
Deafness, ear infections, sinus problems, nasal surgery, throat surgery, tonsils.
- Yes
- No
Orthodontic treatment, dental surgery, speech impairment, harelip, cleft palate, or any other such surgery.
- Yes
- No
Blindness (partial or full), eye surgery, lens implant, cataracts, glaucoma, renitis pigmentosa, renita detachment, impaired vision, or any other eyesight problems.
- Yes
- No
Diabetes mellitus or insipidus, underactive thyroid, overactive thyroid, thyroid surgery, crushing’s syndrome, addison’s disease, pituitary gland, gland problems or any other glandular problems.
- Yes
- No
Neck or back problems or operations, recurrent back pain, osteoporosis, ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, disease, or any other bone or skeletal disorders.
- Yes
- No
Epilepsy, stroke (CVA), migraine, brain or head injuries, spinal cord injuries, paralysis, multiple scelerosis, mental retardation, narcolepsy, motor neuron disease,parkinson’s disease, alzheimer’s disease, or any other neurological problems.
- Yes
- No
Depression, anxiety, psychosis, suicide attempts, biopolar disorders, manic depression, “stress”, schizophrenia, tourete’s syndrome, anorexia nervosa, received advice, counselling or hospitalisation for alcohol or drug abuse, attention deficit disorders, Bulimia or any other psychological conditions.
- Yes
- No
Benign or malignant growths or lumps or tumours including melanomia, lymph gland cancer, leukaemia, breast cancer or any other tumours, growths and cancers.
- Yes
- No
Blood or bleeding disorders e.g. haemophilia, christmas factor deficiency, platelet or any other blood clotting disorders.
- Yes
- No
Eczema, acne, dermatomyositis, psoriasis, scleroderma, or any other skin disorders.
- Yes
- No
Advice, treatments or counselling for any of the following: HIV/AIDS, syphilis, gonorrhoea, herpes, genital ulcers, pelvic infectious disease, genital warts, hepatisis B or any other sexually transmitted disease or disorder.
- Yes
- No
Have you, your spouse or any dependants ever been hospitalised? If yes, provide information below.
- Yes
- No
Are you, your spouse or any dependants expecting any medical or dental advice, treatment, or are you planning any such treatment within the next three to six months?
- Yes
- No
Are you, your spouse or any dependants participating in any hazardous sport or occupations, e.g. motor or motorbike or motorboat racing, dragster racing, bungee jumping, skydiving, scuba diving or any other hazardous pursuits?
- Yes
- No
Are you, your spouse, or any dependants currently pregnant? Should the answer be “yes”, when is the expected date of delivery (yyy/mm/dd)
- Yes
- No
Are there any other factors related to you or your beneficiaries’ health that is not disclosed above?
- Yes
- No
During the last 12 months, have you, your spouse or any dependants had any treatment or are you planning any treatment within the next six months?
- Yes
- No
If the answer to any of the above questions is "yes", please give a short summary.
Section H - Exclusions
In accordance with the registered rules of the Fund, a general waiting period of three (3) months and a specific waiting period of twelve (12) months in respect of confinement and pre-existing medical conditions may be applied if an applicant or beneficiary does not qualify as a continuation member or beneficiary. The applicant or beneficiary hereby acknowledge his/her understanding of the Fund rules and agree to the applicable waiting period and exclusion that may be imposed.
Signature of Applicant
Section I - Documentation
The following documentation should accompany the application form as per the Financial Intelligence Act 2007 (FIA) where applicable:
Document Type
Add Doc
Accepted file types: pdf, docx.
Document Type
Add Doc
Accepted file types: pdf, docx.
Document Type
Add Doc
Accepted file types: pdf, docx.
Section J - Declaration by Applicant / Principal Member
In this declaration the singular shall imply the plural.
1. I the undersigned, hereby apply for myself and my beneficiaries to join as a member of Renaissance Health Medical Aid Fund. 2. I declare that this application and declaration together with statements made by me, whether in writing or not, are true and correct and agree that such statements together with any forms, reports or other information completed or supplied by me or any other party on my behalf shall form the basis of this contract. 3. I agree to be bound and to abide by the rules, standard terms, conditions and any rules ordinarily used by Prosperity Health for types of benefits for which I have applied, and Prosperity Health shall not be bound in any way by any misrepresentations or undertakings made or given by any person or agent. 4. It is further agreed and understood that, notwithstanding any statements made to the contrary by any person, membership will not commence and no liability whatsoever will attach to Renaissance Health unless express written notice of acceptance of risk is given by Prosperity Health. 5. It is also agreed and understood that membership will only commence on the 1st day of the month following receipt of payment by Prosperity Health. 6. I irrevocably authorise any medical practitioner, hospital, medical institution or other person to disclose information which may be related to my occupation, physical or mental health, including the results of any tests, to Prosperity Health and I agree that this authorisation shall remain in force after my death. 7. I indemnify Prosperity Health and it’s creditors, agents and employees against any claim of whatever nature, which may be made against them as a result of or arising out of disclosure, medical information or any costs incurred as a result of being a member of the Medical Aid Fund. 8. I further accept that the provisions of any declaration made have been read and understood by me and will also apply mutatis mutandis to and form part of this application. 9. I authorise Prosperity Health to debit my bank account, details of which have been provided to Prosperity Health, for any amount due in terms of the membership applied for. 10. I undertake to advise Prosperity Health of any change in the status of health of myself, or any of my beneficiaries, which occurs prior to my receiving acceptance of this application. 11. I declare that no material fact has been withheld, misstated or concealed by me and that I will disclose all material facts prior to acceptance of the risk and I agree that any misstatements and / or omission of any material information will render my membership null and void, and in such event all monies paid in respect thereof shall be forfeited. 12. I hereby acknowledge that any credit extended by Renaissance Health Medical Aid Fund to myself or my dependants whilst being members of Renaissance Health Medical Aid Fund, will become payable in full upon termination of my membership of Renaissance Health Medical Aid Fund and that interest may be charged on all amounts owing to Prosperity Health. 13. I further acknowledge that on termination of membership, any amounts owing to the Fund will be deducted from any amounts due to me by my Employer. For this purpose I hereby permit Prosperity Health to advise my Employer of any amounts due to Prosperity Health. 14. I acknowledge that the products offered by the Renaissance Health Medical Aid Fund may incorporate Insurance products of which the risk is fully underwritten by a registered insurer, Prosperity Life in terms of the Medical Aid & Insurance Acts. The terms and conditions of these products can be obtained from the insurer on request. 15. I acknowledge that in the event of any modification or variation of this standard form, Prosperity Health will regard this form as being invalid and of no force and effect. 16. I understand that any changes to this document as well as membership status of any of myself or any of my beneficiaries will require the completion of the necessary forms. 17. I understand and agree to all the above: 18. I hereby acknowledge that I understand the process and that over and under insurance was explained to me. 19. I hereby acknowledge that I understand that there is a maximum cover per insured life. 20. I hereby acknowlegde that I have included my current salary advice / 3 month bank statement as well as declared my current insurance and the reason for it.
Signed at*
on this*

DD
MM
YYYY
day of*
Print Applicant Name*
Applicant / Principal Member Signature
Section K - Employer Warranty
Compulsory for members belonging to Group Scheme
Company Name*
Date*

DD
MM
YYYY
Management Representation
Name*
Designation*
Signature of Company Representative

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I.D / Passport No.	First Name	Surname	Relationship	Gender	Disabled	Date of Birth

Exclusions	Approved By

Level	Family Benefit	Monthly Contribution	Effective Date