Membership Beneficiary Termination Form Download Form Office Use OnlyIntermediary Information (Broker Number)Processed byDate DD MM YYYY Administrator NotesNotesApproved By Section A - Principal Member DetailsMember NumberFirst Name & SurnameTelephone NumberCellphone NumberEmail Address Postal Address* Street Address City State / Province / Region ZIP / Postal Code Spouse Name & SurnameSpouse Cellphone NumberSection B - Employment DetailsType of CompanyPrivateCompanyCB NumberCompany NameTelephone NumberCompany Postal Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employee NumberDate DD MM YYYY Designation of EmployeeManagement RepresentationDate DD MM YYYY NameDesignationSignature of Company RepresentativeCompany StampSection C - Registration of beneficiariesPlease tick appropriate boxMarried (refer to Note 3 below)DivorcedWidowedMy Spouse is not a member of another schemeMy Spouse is a member of a registered scheme (Complete section D)My Spouse is employed at (Name below)Name of CompanyDate of marriage / divorce / death DD MM YYYY BeneficiariesDep CodeFull NamesSurnameDate of BirthBenefit DateAB Section D - Previous/Current Medical MembershipName of previous/current Medical Aid FundMembership NumberDate Joined DD MM YYYY Date Resigned DD MM YYYY Section E - DocumentationNamibian CitizenYesNoI.D / Passport of main memberAccepted file types: pdf, docx.Birth certificates of childrenAccepted file types: pdf, docx.Proof of banking details (Please attach confirmation from the bank)Accepted file types: pdf, docx.Proof of full-time study at a registered technikon or university for child dependents 21 to 25 years of ageAccepted file types: pdf, docx.Payslip for option Evolve Care, Premiere Care and Esteem CareAccepted file types: pdf, docx.Marriage certificate when registering a spouse / I.D / Passport of spouseAccepted file types: pdf, docx.Medical certificate for mentally disabled children over 21Accepted file types: pdf, docx.Identification and Verification: Financial Intelligence Act, 13 of 2012 (FIA)I hereby confirm that the information provided to me by the Policyholder, has been verified against the documentation provided and that the identity of the policy holder has been established and verified as required in terms of Section 21 of the FIA.Broker / Agent NameDate DD MM YYYY Signature of Broker / AgentSection F - Medical HistorySupply 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.YesNoAsthma, difficulty with breathing, bronchospasm, turbeculosis(TB), coughing up blood, emphysema, pneumonia, cystic fibrosis, chronic bronchitis, shortness of breath, any other breathing problems. Smoking.YesNoBlood 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.YesNoEndometriosis, 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.YesNoDuodenal 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.YesNoDeafness, ear infections, sinus problems, nasal surgery, throat surgery, tonsils.YesNoOrthodontic treatment, dental surgery, speech impairment, harelip, cleft palate, or any other such surgery.YesNoBlindness (partial or full), eye surgery, lens implant, cataracts, glaucoma, renitis pigmentosa, renita detachment, impaired vision, or any other eyesight problems.YesNoDiabetes mellitus or insipidus, underactive thyroid, overactive thyroid, thyroid surgery, crushing’s syndrome, addison’s disease, pituitary gland, gland problems or any other glandular problems.YesNoNeck or back problems or operations, recurrent back pain, osteoporosis, ankylosing spondylitis, rheumatoid arthritis, osteoarthritis, disease, or any other bone or skeletal disorders.YesNoEpilepsy, 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.YesNoDepression, 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.YesNoBenign or malignant growths or lumps or tumours including melanomia, lymph gland cancer, leukaemia, breast cancer or any other tumours, growths and cancers.YesNoBlood or bleeding disorders e.g. haemophilia, christmas factor deficiency, platelet or any other blood clotting disorders.YesNoEczema, acne, dermatomyositis, psoriasis, scleroderma, or any other skin disorders.YesNoAdvice, 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.YesNoHave you, your spouse or any dependants ever been hospitalised? If yes, provide information below.YesNoAre 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?YesNoAre 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?YesNoAre you, your spouse, or any dependants currently pregnant? Should the answer be “yes”, when is the expected date of delivery (yyy/mm/dd)YesNoAre there any other factors related to you or your beneficiaries’ health that is not disclosed above?YesNoDuring 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?YesNoIf the answer to any of the above questions is "yes", please give a short summary.Section G - ExclusionsIn 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 ApplicantSection H - Declaration by Principal ApplicantIn 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 SignatureSection I - Disclaimer1. Upon membership being granted, every Member shall, by virtue of his/ her signature on the application form, be deemed to have acknowledged that he/ she and his/ her dependants are bound by the Rules and any annexures and amendments thereto. A copy of the Fund Rules can be obtained from the Fund on request by any Member 2. Upon membership being granted, every Member shall, by virtue of his/ her signature on the application form, consent to the use of their medical data for medical purposes/programs such as managed care programs to be used / disclosed by the Fund to services providers of the Fund subject to confidentiality and protection of the member’s information.Section J - AddendumRHMAF hereby extends its sincerest gratitude to you for considering us as your potential medical aid of choice. Kindly note the below details prior to completing the application form. Please do not resign from your current medical aid fund or medical insurer prior to obtaining approval of your application in writing. Should any further information be required in this regard please feel free to contact the Client Services Department at Tel: +264 83 2999 736. 1. It is very important that the application form be completed in full in order to ensure that all due considered information is provided. 2. We urge you to note the importance of the medical history section in respect of which we encourage prospective members to be most forthcoming as any omission or misrepresentation of fact may have serious consequences in respect of membership. 3. Where the RHMAF elects to effect restrictions or exclusions on the principal member or any of the members’ beneficiaries, this will be communicated in writing to yourself for approval of the restrictions/exclusions, once signed off by yourself, the registration process may then be completed. 4. Where a member applies for membership during the course of a benefit year, it is important to take note that membership will be pro-rated. 5. It may be required that you be requested to provide additional information or undergo medical testing in order to ensure the processing of your application, if this is required you will be duly informed.