Option Amendment Form

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Section A - Member Details
Title*
Initials*
Surname*
First Name*
Second Name
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*
CB Number
Company Name
Section C - 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)
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.
Optional Insurance Products
- Funeral Plan
- Complimed Plus
- Combo (Funeral Cover / Complimed Plus / Hospicash)
Section D - Beneficiaries to be Covered
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*
Applicant / Principal Member Signature
Section F - Employer Warranty
Compulsory for members belonging to Group Scheme
Company Name*
Date*

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

Option Amendment Form

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Level	Family Benefit	Monthly Contribution	Effective Date