Termination Form Download Form Section A - Principal Member DetailsPrivateCompanyMember NumberFirst Name & SurnameCellphone NumberEmployee NumberCompany NameEffective Date of Termination* DD MM YYYY Reason for Termination (Compulsory)Resigned from EmployerJoined spouse’s medical aid fundDismissedDeceased (attach copy of death certificate)RetrenchedPremiums not affordableRetiredBenefitsServiceOther (Please stipulate reason below)Were you offered an alternative optionYesNoStipulate herePrincipal Member SignatureDate DD MM YYYY Section B - Employment WarrantyCompulsory for members belonging to Group SchemeCompany Name*Date* DD MM YYYY Management RepresentationName*Designation*Signature of Company RepresentativeCompany Stamp
