TERMS AND CONDITIONS APPLY | E&OEUNDERWRITTEN BY CONSTANTIA INSURANCE COMPANY LIMITED

CLIENT CLAIM FORM / KLINT EISVORM

2017

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PRINCIPAL INSURED DETAILS / HOOFVERSEKERDE BESONDERHEDE

1) YOUR PROFILE / JOU PROFIEL

2) YOUR CLAIM DETAILS / JOU EIS BESONDERHEDE

PATIENT DETAILS / PASINT BESONDERHEDE

MEDICAL PROCEDURE DETAILS / MEDIESE PROSEDURE BESONDERHEDE

Postal Code /Poskode

Medical Scheme / Mediese Skema Medical Scheme Option / Mediese Skema Opsie Membership Number / Lidmaatskapnommer

Medical Scheme / Mediese Skema Medical Scheme Option / Mediese Skema Opsie Membership Number / Lidmaatskapnommer

Title / Titel First Name / Voornaam Surname / Van ID Number / ID Nommer

Cellphone / Selfoon Telephone (H) / Telefoon (H) Telephone (W) / Telefoon (W)

Date you first experienced symptoms / Datum wanneer jy simptome die eerste keer ondervind het

Symptoms you experienced / Simptome wat jy ondervind het

Stratum Benefits Policy Number /Stratum Benefits Polisnommer

Stratum Benefits Product /Stratum Benefits Produk

Registered Employer Group Scheme /Geregistreerde Werkgewergroep

First Name / Voornaam Surname / Van Relationship / Verwantskap Title / Titel ID Number / ID Nommer

Email Address / E-pos Adres

Hospital / Hospitaal

I aknowledge that the below details are not required when the Principal Insured is the Patient / Ek bevestig dat onderstaande besonderhede nie vereis word as die Hoofversekerde die Pasint is nie

Day Clinic / Dagkliniek

Practitioners Room / Praktisyn se Spreekkamer

Casualty Ward / Ongevalle Eenheid

Other / Ander

Where your medical procedure was performed / Waar jou mediese prosedure gedoen is

Medical condition that was diagnosed / Mediese toestand wat gediagnoseer is Medical procedure that was performed / Mediese prosedure wat gedoen is

Admission or Treatment Date /Opname- of Behandelingsdatum

Discharge Date / Ontslaan Datum

NAME AND CONTACT DETAILS OF PRACTITIONERS / NAAM EN KONTAKBESONDERHEDE VAN PRAKTISYNSGeneral Practitioner / Algemene Praktisyn Contact No / Kontak Nr

Contact No / Kontak Nr

Contact No / Kontak Nr

Practitioner who made diagnosis / Praktisyn wie diagnose gemaak het

Treating Practitioner / Behandelende Praktisyn

Diagnosis Date / Diagnose Datum

Completion of all fields is compulsory in order for your Client Claim Form to be processed. / Voltooing van alle velde is verpligtend vir die verwerking van jou Klint Eisvorm.

Each claimable event requires a separate Client Claim Form to be completed. / Vir elke eisbare voorval moet n aparte Klint Eisvorm voltooi word.

Physical Address / Fisiese Adres Postal Address / Posadres

http://www.stratumbenefits.co.zahttp://www.stratumbenefits.co.za

TERMS AND CONDITIONS APPLY | E&OEUNDERWRITTEN BY CONSTANTIA INSURANCE COMPANY LIMITED

REASON YOU ARE CLAIMING / REDE WAAROM JY EIS

SELECT THE BENEFIT YOU ARE CLAIMING FROM / KIES DIE VOORDEEL WAARVAN JY EIS

COMPULSORY DOCUMENTS TO ATTACH / VERPLIGTE DOKUMENTE OM AAN TE HEG

Your service provider charged a rate considerably more than what your medical scheme paid from your hospital benefit / Jou diensverskaffer het n tarief gehef wat aansienlik meer is as wat jou mediese skema vanuit jou hospitaalvoordeel betaal het

A detailed hospital account in the event of a hospital admission / n Volledige hospitaalrekening in die geval van n hospitaalopname

+All service providers accounts / Alle diensverskaffer rekeninge

+Your medical scheme claims transaction history statement reflecting the amount charged by your service provider and amount paid by your scheme / Jou mediese skema eisestaat wat die bedrag geis deur jou diensverskaffer en bedrag betaal deur jou skema aandui

Your medical scheme applied a rand amount limit to your internal prosthesis, non-PMB day procedure (applicable to G-Force only), MRI or CT scan and you are liable to pay the difference / Jou mediese skema het n randwaarde limiet toegepas op jou interne prostese, nie-VMV dagprosedure (alleenlik van toepassing op G-Force), MRI- of CT-skandering en jy is aanspreeklik vir die verskil

Your medical scheme applied an overall rand amount limit on your hospitalisation and you have exhausted this limit / Jou mediese skema het n oorhoofse randwaarde limiet op jou hospitalisasie toegepas en hierdie limiet is oorskry

Your medical scheme applied a co-payment or deductible to your medical procedure / Jou mediese skema het n bybetaling toegepas op jou mediese prosedure

A detailed hospital or radiology account / n Volledige hospitaal- of radioloog rekening

+Your medical scheme claims transaction history statement reflecting the co-payment / deductible OR proof of payment if co-payment / deductible was paid upfront / Jou mediese skema eisestaat wat die bybetaling aandui OF bewys van betaling indien bybetaling vooraf betaal is

You are claiming from your Gap Policy Premium Waiver Benefit due to the death, permanent disability or forced retrenchment of the premium payer / Jy eis van jou Gapingpolis Premiekwytskeldingsvoordeel as gevolg van die sterfte, permanente ongeskiktheid of geforseerde diensaflegging van die premiebetaler

Death certificate, doctors confirmation of permanent disability or employers confirmation of forced retrenchment respectively / Doodsertifikaat, bevestiging van geneesheer wat permanente ongeskiktheid bevestig of werkgewer bevestiging van geforseerde diensaflegging onderskeidelik

+Proof from bank confirming premium payer / Bewys van bank wat premiebetaler bevestig

You are claiming from your Medical Scheme Contribution Waiver Benefit due to the death or permanent disability of the premium payer / Jy eis van jou Mediese Skema Bydrae Kwytskeldingsvoordeel as gevolg van die sterfte of permanente ongeskiktheid van die premiebetaler

Death certificate or doctors confirmation of permanent disability respectively / Doodsertifikaat of bevestiging vanaf geneesheer van permanente ongeskiktheid onderskeidelik

+Proof from bank confirming premium payer / Bewys van bank wat premiebetaler bevestig

You are claiming from your Accidental Death Benefit due to the accidental death of the principal insured, spouse or dependant / Jy eis van jou Ongeluksterftevoordeel as gevolg van die ongeluksdood van die hoofversekerde, gade of afhanklike

Death certificate / Doodsertifikaat

Your medical scheme has only paid a portion of your oncology treatment and you are liable to pay the difference / Jou mediese skema het n oorhoofse randwaarde limiet toegepas op jou onkologie voordeel en hierdie limiet is oorskry

Copy of your approved oncology treatment plan / Afskrif van jou goedgekeurde onkologie behandelingsplan

+All service providers accounts / Alle diensverskaffer rekeninge

+Your medical scheme claims transaction history statement reflecting the amount charged by your service provider and amount paid by your scheme / Jou mediese skema eisestaat wat die bedrag geis deur jou diensverskaffer en bedrag betaal deur jou skema aandui

Your medical scheme has applied an overall rand amount limit to your oncology benefit and you have exhausted this limit / Jou mediese skema het n oorhoofse randwaarde limiet toegepas op jou onkologie voordeel en hierdie limiet is oorskry

You have been diagnosed with cancer for the first time since your cover started / Jy is vir die eerste keer met kanker gediagnoseer nadat jou dekking begin het

Healthcare providers confirmation of first time cancer diagnosis / Bevestiging van mediese praktisyn wanneer kanker die eerste keer gediagnoseer is

+Copy of your medical scheme approved oncology treatment plan / Afskrif van jou mediese skema se goedgekeurde onkologie behandelingsplan

You are claiming for a casualty event where immediate treatment was required due to physical injury / Jy eis vir n ongevalle voorval waar onmiddellike behandeling nodig was weens n fisiese besering

A detailed casualty report and casualty account / n Volledige ongevalle verslag en ongevalle rekening

+Your medical scheme claims transaction history statement reflecting the amount charged by your service provider and amount paid by your scheme / Jou mediese skema eisestaat wat die bedrag geis deur jou diensverskaffer en bedrag betaal deur jou skema aandui

You are claiming for the consultation fee charged by your registered counsellor, clinical psychologist or psychiatrist due to a traumatic event that occurred / Jy eis vir die konsultasiefooi gehef deur jou geregistreerde berader, kliniese sielkundige of psigiater vir n traumatiese gebeurtenis wat plaasgevind het

Counsellors report and account / Berader se verslag en rekening

+Your medical scheme claims transaction history statement reflecting the amount charged by your service provider and amount paid by your scheme / Jou mediese skema eisestaat wat die bedrag geis deur jou diensverskaffer en bedrag betaal deur jou skema aandui

You are claiming for a medical procedure which your medical scheme has listed as a specific exclusion / Jy eis vir n mediese prosedure wat jou mediese skema gelys het as n spesifieke uitsluiting

Quotations from all service providers such as the hospital, doctors and specialists / Kwotasies van alle diensverskaffers soos die hospitaal, dokters en spesialiste

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BENEFIT CATEGORIES & SUPPORTING DOCUMENTS / VOORDEEL KATEGORIE & ONDERSTEUNENDE DOKUMENTE

Nexus statements are not accepted as medical scheme transaction history statements. Refer to Your Policy Particulars or contact your broker or Stratum Benefits directly for more information regarding your underwriting and exclusions which may apply to your policy benefits. / Nexus-state is nie aanvaarbare mediese skema eisestate nie. Verwys na Jou Polis Besonderhede of kontak jou makelaar of Stratum Benefits direk vir meer inligting oor jou onderskrywing en uitsluitings wat van toepassing mag wees op jou polisvoordele.

GAP BENEFIT / GAPING VOORDEELBase, Co-Evolution, Elite, Corporate Elite, Senior & G-Force

SUB-LIMIT BENEFIT /SUB-LIMIET VOORDEELElite, Corporate Elite, Senior & G-Force

CO-PAYMENT BENEFIT /BYBETALING VOORDEELCo-Evolution, Elite, Corporate Elite, Senior & G-Force

GAP POLICY PREMIUM WAIVER /GAPINGPOLIS PREMIEKWYTSKELDINGElite, Corporate Elite & G-Force

CASUALTY BENEFIT /ONGEVALLE VOORDEELBase, Co-Evolution, Elite, Corporate Elite, Senior & G-Force

CANCER DIAGNOSIS BENEFIT /KANKER DIAGNOSE VOORDEELBase, Co-Evolution, Elite, Corporate Elite & G-Force

ONCOLOGY BENEFIT /ONKOLOGIE VOORDEELElite, Corporate Elite, Senior & G-Force

ONCOLOGY OPTIMISER BENEFIT /ONKOLOGIE OPTIMISER VOORDEELElite, Corporate Elite & G-Force

MEDICAL SCHEME CONTRIBUTION WAIVER / MEDIESE SKEMA BYDRAE KWYTSKELDINGElite, Corporate Elite & G-Force

TRAUMA COUNSELLING BENEFIT / TRAUMA BERADING VOORDEELBase, Co-Evolution, Elite, Corporate Elite, Senior & G-Force

ACCESS OPTIMISER BENEFIT / ACCESS OPTIMISER VOORDEELAccess Optimiser & Corporate Access

ACCIDENTAL DEATH BENEFIT /ONGELUKSTERFTEVOORDEELElite, Corporate Elite & G-Force

HOSPITAL OPTIMISER BENEFIT / HOSPITAL OPTIMISER VOORDEELHospital Optimiser

I have attached a copy of my latest medical scheme membership certificate or membership card / Ek het n afskrif van my nuutste mediese skema lidmaatskapsertifikaat of lidmaatskapkaart aangeheg

I have attached the below compulsory documents relevant to my claimable benefit (Any outstanding documents will result in you having to resubmit your entire claim) / Ek het die verpligte dokumente aangeheg wat betrekking het op my eisbare voordeel (Uitstaande dokumente sal vereis dat n heel nuwe eis ingedien moet word)

2) YOUR CLAIM DETAILS CONTINUED / JOU EIS BESONDERHEDE VERVOLG

http://www.stratumbenefits.co.za

TERMS AND CONDITIONS APPLY | E&OEUNDERWRITTEN BY CONSTANTIA INSURANCE COMPANY LIMITED

Please enquire if you have not received feedback within 7 days from submitting your Client Claim Form. / Doen asseblief navraag as jy nie binne 7 dae vanaf die indiening van jou Klint Eisvorm terugvoering ontvang het nie.

3) YOUR CLAIM REIMBURSEMENT PROFILE / JOU EIS VERGOEDINGSPROFIELStratum Benefits (Pty) Ltd reserves the right to negotiate a discounted rate with the relevant service providers on your behalf to ensure you maintain a favourable risk profile. If granted, payment will be made directly into the respective service providers bank account thus rendering section 3 of the Client Claim Form null and void. Banking details provided as part of your Claim Reimbursement Profile will be the only bank account used for claim reimbursements. Stratum Benefits (Pty) Ltd accepts no responsibility and cannot be held liable for any incorrect banking details provided for claim reimbursements. / Stratum Benefits (Edms) Bpk behou die reg om namens jou afslag te beding met die betrokke diensverskaffers om te verseker dat jy n gunstige risiko-profiel behou. Wanneer kortings beding word, sal betalings direk aan die diensverskaffers gemaak word wat afdeling 3 van die Klint Eisvorm nietig maak. Die bankbesonderhede soos aangedui op jou Eis Vergoedingsprofiel is die enigste bankrekening wat vir die terugbetaling van eise gebruik sal word. Stratum Benefits (Edms) Bpk aanvaar geen verantwoordelikheid of aanspreeklikheid vir enige foutiewe bankbesonderhede met eise terugbetalings nie.

RETURN TO STRATUM BENEFITS (PTY) LTD / STUUR TERUG AAN STRATUM BENEFITS (EDMS) BPKREG NO: 2003/018155/07

e yourclaim@stratumbenefits.co.zaf 086 633 3761

AUTHORISATION & DECLARATION ACCEPTANCE / MAGTIGING & VERKLARING AANVAARDINGI hereby authorise my medical scheme and any service provider whom attended to me or any of my dependants, to furnish Stratum Benefits (Pty) Ltd or its authorised representatives information in respect of any medical condition, the medical history thereof and / or benefit information which may be required for the assessment of my claim. I declare that the details provided, as well as any supporting documents supplied are true and correct and I understand that any non-disclosure or false representation may result in the rejection of this claim and / or cancellation of cover. / Ek magtig hiermee my mediese skema en enige diensverskaffer wat dienste aan my of my afhanklikes verskaf het, om Stratum Benefits (Edms) Bpk of hul gemagtigde verteenwoordigers met inligting te voorsien wat met my of my afhanklikes se mediese toestand, die mediese geskiedenis daarvan en / of voordeel inligting verband mag hou te verskaf en nodig mag wees om my eis te verwerk. Ek verklaar hiermee dat die inligting en ondersteunende dokumente wat ek verskaf het juis en korrek is en begryp ek dat enige verswyging van feite of vals inligting kan lei tot die verwerping van die eis en / of die kansellasie van dekking.

Bank / BankAccount Holder / Rekeninghouer Account Number / Rekeningnommer

Account Type /Tipe Rekening

Cheque /Tjek

Savings /Spaar

Account Holder Signature / Handtekening van Rekeninghouer

Date / DatumPrincipal Insured Signature / Hoofversekerde Handtekening

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