LMS Application for Membership 2012

8/2/2019 LMS Application for Membership 2012

1/12

Priate Bag X35

Careont, 7735

Contact Centre 0860 002 163

New Bine ax 021 657 7651

www.ibed.co.za

Page 1 o 12

Ima:

Peae write cear ing capita and bock etter.

It i copor or fed arked with * to be copeted. Appication actiated with ter accepted ae the onth ct-o or New Bine (20th o the onth), ight be bject to Contribtion arrear. Peae bit copeted or to: [email protected] or ax: 021 657 7651. Backdating wi NOT be peritted.

Peae note that i o are not atifed with an o the Ter on receipt o or Wecoe etter, o a cance thi appication within thefrt 30 da o eberhip. A ciui aid wi e euded idi eef hae ee uiied .

Exiting eber who wih to regiter additiona dependant(), peae copete the Dependant Regitration or.

OR ADmINIsTRATIvE usE ONly

meberhip nber

Grop nber l B T Interchangeabiit y N

section 1 details of principal member

Peae eae a pace between nae. * Dee Cmu Imai

srnae*

maiden nae (i appicabe)*

Tite* irt nae()*

Initia* Date o birth* y y y y m m D D

Gender* m marita tat* sINGlE mARRIED DIvORCED WIDOWED COmmON-lAW

sA ID nber*

Teephone (Hoe)* (Work)*

ax Ce*

Eai

I agree to receiing correpondence ia eai y N

Preerred conication EmAIl POsT

(B chooing eai o wi receie or conication qicker with e enironenta ipact.)

Pota addre*

Pota code

Phica addre* sae a pota y N

I No

Pota code

soker* y N Weight * kg Height* c

Aicai Memehi 2012


2/12

Page 2 o 12 | Appication or meberhip 2012

section 2 - choice of option details

Join schee ro y y y y m m D D

Idicae i wih X i he aiae x

Patin Copete TitanPatin saer God saer Bona P

Patin oc God oc

p m s f (msf) --

Exce aont (the dierence between the libert medica schee reibreent rate and the aont charged b a heathcare proider),a we a aont caied in exce o beneft b-iit or da-to-da cai except or edicine, wi atoatica be paid ro a poitiebaance in or medica saing aciit. On the libert medica schee rate wi accate to or Threhod ee. Thi a ipact orThrehod Beneft and ret in a higher se-Paent Gap.

cu m s f

On the oowing option hae a aing aciit incded in the tota contribtion:Patin Copete 15% Titan 15% Patin saer 10% God saer 15%

section 3 employment details

Are o apping a:

Indiida meber Epoer Grop meber Pera meber

Nae o Epoer

Teephone nber ax

Eai

Date o epoent y y y y m m D D Epoee/Pera nber

(Pera nber or goernent epoee. Peae attach a cear cop o or atet aar ip)

(Peae enre or epoer copete thi decaration i thi appication or i not bitted together with an Epoer Grop Regitration or)

EMployEr DEClArAtIon

1. We confr that the appicant detaied in section 1 i an epoee o or organiation.2. The schee a bi or the aont de or thi eber in the ae wa a it doe or or other epoee with the schee.

COmPANy sTAmP

Athoried signator Deignation

Date

section 4 dependants to be registered

It i copor to copete thi ection i o hae an dependant o wod ike to add and proide copie o pporting docentation.

The granting o dependant eberhip i trict bject to the re and approa o the schee. peae cmee ID ume i u.

* Dee Cmu Imai

Deeda 1

Tite* Initia()* srnae*

irt nae()* (a per identit docent)

marita tat Gender* m Date o birth* y y y y m m D D

Reationhip to Principa eber*(or exape other, chid. Where or chid i not or bioogica chid, peae tatereationhip. or exape adopted chid, oter chid. Peae proide ega proo)

ID nber* soker* y N Weight* kg Height* c

I or dependant: arried? y N fnancia dependent on o? y N diabed y N a -tie tdent? y N

Doe or dependant earn an incoe? y N How ch doe or dependant earn each onth? R


3/12

Appication or meberhip 2012 | Page 3 o 12

Deeda 2

Tite* Initia* srnae*



Reationhip to Principa eber* (or exape other, chid. Where or chid i not or bioogica chid, peae tatereationhip. or exape adopted chid, oter chid. Peae proide ega proo)




Deeda 3








Deeda 4








Deeda 5








Deeda 6









4/12


Deeda 7




Reationhip to Principa eber* (or exape other, chid. Where or chid i not or bioogica chid, peae tatereationhip. or exape adopted chid, oter chid. Peae proide ega proo)




Deeda 8








(peae cmee a a ae i u hae me deeda eie.)

DEClArAtIon or DEpEnDAnts

1. I hereb decare that I a nder a ega obigation to aintain the dependant ited on appication or.2. I decare that dependant (excding poe) are not in receipt o a regar reneration o ore than the tax threhod per ann or

peron beow the age o 65 ear.

signatre o Principa eber Date

DEClArAtIon or pArtnEr

I hereb decare that partner and I are in a coitted and peranent reationhip. We are fnancia dependent on each other and we haea hared and coon hoehod.



5/12


dependantsacceptedbylmsan

ddocUmentsreQUiredforregistration

du

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lawu

spoue

lie

Partner

Bioogica

Parent

omeber

***

Bioogica

sibingo

meber

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meberOwn

m

inorChidren

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AdutChidren,

inc

stepchidren

***

Peranenty

Diabed

Chidren

stepchidren

***

Adopted

Chidren

******

CopyoID/BirthCerticate/hopitaconrationrefectingthebabynae

CopyomarriageCerticate

CopyomeberhipCerticate()/Adavitdetaiingprevioueberhiphitory*

AdavitconringnanciadependencyoBioogicaParen

t()**

Prooo

incoeiepoyed****

Prooo

tudie(currentproooregitrationatarecognied

educationaintitution)

AdavitconringnanciadependencyoAdutDependant()**

CopyotheDoctordiabiityreport

Prooo

egaadoption

*

CoyoMembehiCetifcate()/Afdavitdetaiing

evioumembehihitoy(regitrationdate,

benetdate,

reignationdate,

any/awaitingperiodan

dexcuion,

aregitereddependant).meberhip

cardorcopie

th

ereowinotbeaccepted.

Inotattached,

thelateJoinerPenatyayappy.

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lMsAfdavittemateaeavaiabeonwww.

ibmed

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subjecttoAnnuareview

bpm:Fathers-in-lawandmothers-in-lawarenotaccepted

bs:Biologicalsiblings>21willbech

argedadultrates

auch,.sh:>21anduptoan

dincludingtheageo26willbechargedadultratesunlessaull-timestudentatarecognisedinstitutionordisabled.

****

poooincomemutbeovidedaoow:

Copyodependantsmostrecentpaysliporsalarya

dviceorgovernmentgrantcard

Commissionstatementsorthelast12months

CopyodependantslatestSARSincometaxreturn

Writtenconfrmationoincomeromdependantsh

umanresourcesdepartment,onacompanyletterhea

d

Iunemployed,yourUnemploymentInsuranceFund(UIF)bluebookoradischargecertifcateromyour

previousemployerorafdavitstatingzeroincome.

*****M

embeownnewbonchiden:Iregitrationwith

lmstakepacewithin30dayothebirthnowaitin

gperiodiipoed.

(TheDependantRegitrationo

riavaiabeonthewebite:www.

ibed.c

o.z

a).

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dotedChiden:Nowaitingperiodiipoedireg

itrationwithlmsicopetedwithin30dayothe

adoption.

(TheDependantRegitrationoriava

iabeonthewebite:www.

ibed.c

o.z

a).


6/12


section 5 previoUs medical scheme membership

Peae proide detai o preio edica chee eberhip.

Peae attach reeant Proo o meberhip. Thi a be a worn afdait detaiing preio eberhip hitor (regitration date, beneft date,reignation date, an/a waiting period and excion, a regitered dependant). meberhip card or copie thereo wi not be accepted.I not attached, or sufcient proo provided, the Late Joiner Penalty may still apply.

s

m

u

a/ u

?

a u

?

d j d r

y N y N y y y y m m D D y y y y m m D D












section 6 Underwriting information

Peae enre that o hae copeted section 5.I u awe a quei i 6.1, u mu cmee a he medica quei i seci 6.3.

section 6.1

I confr that a dependant naed on thi appication:

1. are crrent or hae been eber o a regitered soth Arican medica schee or at eat the pat 24 onth, and y N2. hae not had a break in eberhip o ore than 90 da ince reigning ro that regitered soth Arican medica schee y N

I u aweed e h he ae quei, eae awe he quei i seci 6.2.

I u aweed a quei i seci 6.1 u mu cmee seci 6.3.

section 6.2

or an dependant naed on thi appication or:

1. Hae the been aditted to hopita in the at 12 onth beore thi appication? y N

2. Are the crrent taking regar edicine or reaonab expecting to need edicine? y N

3. Are the panning to or reaonab expecting to be hopitaied (incding or pregnanc) or expecting to receie denta oredica treatent?

y N

I u aweed e a quei i 6.2, we wi a a hee-mh eea waii eid u aicai ad u d hae

cmee seci 6.3.

Dring thee three onth, we wi on coer cai reating to Precribed mini Beneft according to the schee Re.

I u ee ha a hee-mh eea waii eid hud e aied ad u wa ide u wih addiia imai, eae

cmee seci 6.3.

I u hae aweed a he quei i seci 6.2, u aicai wi e eiewed a e u i fe deemie i a

hee -mh waii eid wi e imed.

Peae note that late Joiner Penatie ight app.


7/12


section 6.3 health QUestionnaire

A ection beow to be copeted b appicant - aire to do o wi dea proceing. Peae gie detai on the qetion beow. Qetionpertain to a additiona dependant.

notE: I o anwered yEs to an o the qetion in thi ection, and i the pace proided to copete or anwer i not fcient to dicoethe necear inoration, peae proide additiona inoration on eparate page.

Crrent ai doctor

Nae and rnae

Teephone How ong ha he/he been or doctor? ear()

Pota addre

Pota code

Hae o/or poe or an o or dependant eer receied edica adice, diagnoi, care or treatent or an o the oowing condition inthe at 12 onth?

1. h &

cu

Chet pain/Angina; Heart attack; Heart aire; Heart ae deect; Rheatic eer; High bood prere(Hpertenion); High choetero; Heart rr; Circator probe/diorder; varicoe ein; Deep veinThroboi (DvT) or an other heart or circator probe

y N

Deeda Cdii Medicai receii

eame

Dae eame/

hiaiai

paciie/eciai

y N y y y y m m D D Nae:

y N y y y y m m D D Te:

2. b &

r

Atha; Difct with breathing; Bronchopa; Tbercoi (TB); Coghing p bood; Ephea; Pneonia;Ctic ibroi; Phthii; Chronic bronchiti; shortne o breath or an other breathing probe y N


eame

Dae eame/

hiaiai

paciie/eciai



3. b &

K

Bood in rine; Kidne aire; Poctic Kidne; Kidne or badder inection; Kidne reoa (Nephrecto);Kidne tone; Abnora Kidne or rine tet or an other badder or kidne probe

y N


eame

Dae eame/

hiaiai

paciie/eciai



4. ruo

Endoetrioi; Inertiit; Oarian Ct; Hterecto; Abnora Pap sear; laer treatent; Cerix and BreatBiopie; ibro-adenoi o the Breat; laparocopie; receiing Horone Repaceent Therap (HRT); Protateinection or rger; Protate enargeent or an other reprodctie probe

y N


eame

Dae eame/

hiaiai

paciie/eciai



5. d

s

Dodena ucer; Gatric ucer; Peptic ucer; Hiat Hernia; Coon probe; Crohn Dieae; uceratie Coiti;

Ga Badder probe; lier probe or an other digetie te probey N


eame

Dae eame/

hiaiai

paciie/eciai



6. e, n &

t

Deane; Ear inection; sin probe; Naa rger; Throat rger; Orthodontic; Denta rger;speech ipairent; Hareip; Cet Paate or an other noe or throat probe

y N


eame

Dae eame/

hiaiai

paciie/eciai




8/12


7. e Bindne (partia or ); Ee rger; len ipant; Cataract; Gacoa; Retiniti Pigentoa; Retina Detachent;Ipaired iion or an other ee or eeight probe

y N


eame

Dae eame/

hiaiai

paciie/eciai



8. e Diabete (high bood gar); underactie Throid; Oeractie Throid; Throid rger; Ching sndroe;Addion Dieae; Pititar Gand probe or an other gandar probe

y N


eame

Dae eame/

hiaiai

paciie/eciai

y N Nae:

y N Te:

9. bk &

mu

Neck or back probe or operation; Recrrent back pain; Oteoporoi; Ankoing sponditi; Rheatoid Arthriti;Oteo-Arthriti; Paget Dieae or an other bone or keeta diorder

y N


eame

Dae eame/

hiaiai

paciie/eciai



10. nu Epiep; stroke (CvA); migraine; Brain injrie; spina Cord injrie; Parai; Cerebra Pa; mtipe sceroi;menta retardation; Narcoep; motor Nerone Dieae; Parkinon Dieae; Azheier Dieae or an otherneroogica probe

y N


eame

Dae eame/

hiaiai

paciie/eciai



11. p Depreion; Anxiet; Pcoi; sicide attept; Bipoar Diorder; manic Depreion; stre; schizophrenia;Torette sndroe; Anorexia Neroa; Receied adice, coneing or hopitaiation or Achoho or Drg abe;Attention Defcit Diorder; Biia or an other pcoogica probe

y N


eame

Dae eame/

hiaiai

paciie/eciai



12. tuu &

g

Benign or maignant growth or p or tor incding: meanoa; lph Gand Cancer; lekaeia and BreatCancer or an other tor, growth and cancer

y N


eame

Dae eame/

hiaiai

paciie/eciai



13. b Bood or beeding diorder e.g. Haeophiia; Chrita actor defcienc; Pateet or an other bood cotting diordery N


eame

Dae eame/

hiaiai

paciie/eciai



14. sk Eczea; Acne; Deratooiti; Pephig; Poriai; scerodera or an other kin diordery N


eame

Dae eame/

hiaiai

paciie/eciai




9/12


15. sxu

t

d

Adice, treatent or coneing or an o the oowing: HIv/AIDs; sphii; Gonorrhoea; Herpe; Genita ucer;Peic Inectio Dieae (PID); Genita Wart; Hepatiti B or an other exa tranitted dieae or diorder y N


eame

Dae eame/

hiaiai

paciie/eciai

y N y y y y m m D D Nae:y N y y y y m m D D Te:

16. t Are o, or poe or an o or dependant expecting an treatent/procedre/hopitaiation within the next12 onth?

y N


eame

Dae eame/

hiaiai

paciie/eciai



17. h Hae o, or poe or an o or dependant, been hopitaied in the at fe (5) ear?y N


eame

Dae eame/

hiaiai

paciie/eciai

y NNae:

y N Te:

18. p Are o/ or poe/ an o or dependant crrent pregnant?I he awe hi quei i ye, whe i he execed dae deie?

y y y y m m D Dy N


eame

Dae eame/

hiaiai

paciie/eciai



19. d Do o, or poe or an o or dependant hae diabiitie not entioned in the aboe qetion 1 to 18?y N


eame

Dae eame/

hiaiai

paciie/eciai



DEClArAtIon or HEAltH InorMAtIon:

1. I warrant that the inoration I hae proided pertaining to e and dependant i tre, correct and copete and that I hae notconceaed, withhed or itated an ateria act. shod there be an non-dicore or ateria irepreentation, I accept that eberhip a be terinated and that I a oreit contribtion to the schee. libert medica schee ao ha the right to caidaage in repect o an o or daage it a er de to non-dicore or irepreentation.

2. I ndertake to propt adie the schee o an change in tat o heath o e or an o dependant that occr prior to receiing acceptance o thi appication. I acknowedge that not doing o a ead to the schee reconidering the bai o eberhipappication.

3. I accept that waiting period or ate joiner penatie a be appied, baed on prior edica chee eberhip inoration I ppied, a

proided or in the medica schee Act (Act No.131 o 1998).



10/12


section 7 banKing details of principal member

Ue hi accu All aaci: dei de iuci cec ciui a we a dei caim eud

Ue hi accu only dei de ciui ceci

nae o accont hoder

Nae o bank

Branch nae Branch code

Accont tpe CHEQuE TRANsmIssION sAvINGs

Accont nber

ne:

Peae note that the deat eectie/odgeent date or a debit order wi be on the frt bine da o the onth

Credit card detai are not acceptabe

Principa eber ignatre Date y y y y m m D D

Accont hoder ignatre Date y y y y m m D D

(i dierent ro Principa eber)

Ue hi accu ai/caim eud

nae o accont hoder

Nae o bank

Branch nae Branch code

Accont tpe CHEQuE TRANsmIssION sAvINGs

Accont nber

Principa eber ignatre Date y y y y m m D D

Accont hoder ignatre Date y y y y m m D D

(i dierent ro Principa eber)

DEClArAtIon or bAnkIng DEtAIls

1. I intrct libert medica schee to eectronica coect contribtion and to depoit cai and aing nd, ia the ACB eectronicte, ing the inoration proided aboe. I ndertand that traner cannot be done to and ro credit card accont. I aoirreocab athorize libert medica schee to reere an erroneo tranaction and/or recti an eectronic traner o nd withotprior notice.

2. I athorie libert medica schee to debit bank accont or contribtion and an other aont that a becoe de b e.3. I athorie the schee to contact bank, hod it need to eri an o bank accont detai. I ao agree to adie the schee in

writing o an change to banking detai. aire to do o wi ret in e being iabe or an beqent banking charge incrred.4. I athorie the schee to coect, proce and hare perona banking detai with an contracted Third Part Proider in order to aow

the schee to f it nction, dtie and obigation.5. I hereb confr that the bank accont detai in section 7 aboe are correct.6. upon joining the Bona P option, I hereb athorie libert medica schee to rnih bank accont detai to CareCro.

I athorie CareCro to pa an edica chee beneft that a be de to e, to thi bank, or an other, to which I ight change theaccont.



11/12


section 8 declaration by principal member

a uj m s a n. 131 1998 .

1. I, the undersigned, hereby apply or mysel and my dependants to join the Liberty Medical Scheme (the Scheme) and declare that this application and declarations

together with the statements made by me, whether in my handwriting or not, are true and correct and agree that such statements together with any orms, reports

or other inormation completed or supplied by me or any party on my behal shall orm the basis o the contract.2. It is urther agreed and understood that, notwithstanding any statement made to the contrary by any person, membership will not commence and no liability

whatsoever will attach to Liberty Medical Scheme as a result o this application (completed in ull with supporting documentation attached), unless and until the

frst contribution has been paid and received by Liberty Medical Scheme and express written notice o acceptance o the risk is given by Liberty Medical Scheme.

The Underwriting Acceptance letter shall be valid or a period o three months only rom date o registration.

3. Scheme Rules and Benefts:

I agree to be bound and to abide by the Scheme rules, standard terms, conditions and any rules ordinarily used by Liberty Medical Scheme or the type o

benefts or which I have applied, and that Liberty Medical Scheme shall not be bound in any way by any representations or undertakings made or given by any

person or agent save as contained in the registered rules o the Scheme.

I understand that certain benefts in the frst year o my membership, once membership has been confrmed by the Scheme, are pro-rated and that I will not be

entitled to a ull years cover i I join or change my existing option ater 1 January o a year.

4. Contributions and amounts owed to The Scheme:

I acknowledge that it remains my responsibility to ensure that the monthly contribution, or other amounts due, are received by the Scheme.

I accept that the Scheme has the right to amend monthly contributions and benefts rom time to time.

I accept that should contributions, or other amounts due be unpaid, that this will result in the suspension o my own and my dependants benefts and i they

remain outstanding, that the Scheme will discontinue my membership.

I also accept that I will be responsible or the legal costs associated with the recovery o arrears.

5. Disclosure o inormation:

I declare that no material act has been withheld, misstated or concealed by me and that I will disclose all material acts prior to acceptance o the risk and I

agree that any misstatement and/or omission o any material inormation will render my membership null and void, and in such an event all monies paid in

respect thereo shall be oreited.

I understand that should there be any additional inormation required by the Scheme that is not received within 14 days, that the Scheme has the authority to

suspend my application or membership.

I indemniy Liberty Medical Scheme and its trustees, agents and administrator against any claim, o whatever nature, which may be made against them as a

result o or arising out o the disclosure o any test results or medical inormation.

I irrevocably authorise any medical practitioner, hospital, medical institution or other person to disclose inormation which may be related to my own, or my

dependants, past or uture occupation, physical or mental health, including the results o any tests, to Liberty Medical Scheme, its administrator or managed

health care agent and I agree that this authorisation shall remain in orce ater my/their death/s.

I irrevocably authorise the Scheme to collect, process and share my personal inormation with any contracted Third Party Provider in order to allow the Scheme

to ulfl its unctions, duties and obligations. I agree that this authorisation shall remain in orce ater my/their death/s and understand that this may partially

limit my right to privacy.

6. Resignation:

I hereby acknowledge that any credit extended by Liberty Medical Scheme to mysel or my dependants whilst being members o Liberty Medical Scheme will

become payable in ull upon resignation o my membership o the Scheme and that interest may be charged on all amounts due and owing to LibertyMedical Scheme.

I urther acknowledge that on resignation o membership, any amounts owing to the Scheme will be deducted rom any amounts due to me by my Employer.

For this purpose I hereby permit Liberty Medical Scheme to advise my employer o any amounts due to the Scheme where applicable.

I, the undersigned, confrm that I understand that it is illegal to belong to more than one registered medical scheme at a time and that all my dependants and I

will resign our current medical membership with my/our current scheme prior to joining Liberty Medical scheme.

I understand that according to the rules, I may resign my membership o the Scheme on giving one calendar month written notice and that all rights to benefts

cease ater the last day o my membership.

7. Personal Contact details:

I understand that Liberty Medical Scheme may provide written notifcation to my email address or postal address, ailing which, my brokers email address as

supplied by my broker, o changes to its Rules.

I consent to my telephone conversations with the Liberty Medical Scheme being recorded and orming part o the Schemes records.

I also agree that such records shall remain the sole property o Liberty Medical Scheme.

I consent to the use o all contact details given in this application, by Liberty Medical Scheme, or any appointed agent(s) o the Scheme, to send me inormation

pertaining to my membership (confdential or other).

I undertake to inorm the Scheme, in writing, o change o contact details.

8. Marketing:

In order to keep o pdated on actiitie at libert medica schee (lms), we wod ike to conicate, where necear, ia eai, and pot.

Do o wih to receie lms arketing conication? y N

I e, how wod o ike to receie the? Eai y N sms y N Pot y N

I conent to lms arketing prodct, erice and pecia oer being ent to e ro tie to tie. y NI conent to lms haring eberhip inoration with an Third Part Proider contracted to lms or the deier o heathcare erice toaow the schee to f it nction. y N

I conent that ch contracted Third Part a contact e ro tie to tie regarding their prodct, erice and pecia oer. y N

9. I hereby appoint the fnancial adviser, who has submitted this application on my behal, to be my nominated fnancial adviser.

10. I Further accept that the provisions o any previous declaration made in respect o the Scheme has been read and understood by me and will

also apply mutatis mutandis to and orm part o this application.

signed at on thi da o 20 signatre o Principa eber


12/12


1483_EngAPP_0112

section 9 to be completed by financial adviser (intermediary)

Nae and rnae

inancia Adier Coiion code

Are o accredited with the Conci or medica schee? y N

I yEs peae proide Accreditation nber Date accredited y y y y m m D D

Branch nae Ce

Ofce Teephone Other nber

Eai addre

secondar eai addre (e.g. Broker Contant)

Additiona intrction b fnancia adier (interediar) to libert medica schee adinitration

inancia Adier signatre Date y y y y m m D D

r a (Appicabe to Agent and ranchie broker on)

Anai date y y y y m m D D

Prodced or

ID nber

Option that atche or need baed pre on or ie tage egentation

Da-to-da coer reqired

Non-PmB Chronic Coer reqired

Threhod Coer reqired

Option that atche or need baed on or ie tage egentation and conidering the aboe pecifc heath and fnancia need.

Recoended lms Option

Acta lms Option choen

Reon or chooing other option

rECorD o ADvICE I DEClArE tHAt:

1. I a appointed b the cient to proide adice abot thi appication.2. I hae a aid contract with libert medica schee.3. I a reponibe or proiding the appicant with:

nae, phica addre, pota addre and teephone nber ipartia adice that i in hi or her bet interet

4. I a accontabe or an adice gien to the appicant abot copetion o thi appication or and joining the schee.

inancia Adier signatre Date

Documents

LMS Application for Membership 2012