maxima APPLICATION FORM

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1 axia APPLICATION OR SECTION 1 CHOICE O OPTION Choose ONE prouct option b placing x in the appropriate box Coprehensive Options Saver Options Hospital Plans AXIA PLUS AXIA ADVANCED AXIA CORE AXIA EXEC AXIA BASIS* AXIA COREGRID AXIA BASISGRID* AXIA ENTRYZONE AXIA STANDARD AXIA STANDARD Elect AXIA SAVER* AXIA SAVERGRID* *Please also coplete Section 9 for noination of a ehealth network P (ail Practitioner) AXIA ENTRYSAVER* I wish to join the schee fro SECTION Contribution collection in ADVANCE Contribution collection in ARREARS DETAILS O PRINCIPAL OR EBER INCOE VERIICATION AXIA DYNAIC SAVER Surnae aien nae (if applicable) irst nae/s Preferre nae Gener ID/ passport nuber Tax Nuber Telephone (H) ( ) phone nuber Telephone (W) ( ) ax ( ) E-ail aress Postal aress Postal coe Phsical aress Postal coe Countr Have ou ha previous eical ai cover? Are ou changing our eical schee ue to a change in our eploent? If es, please provie etails below Nae of previous eical schee ebership nuber Date joine Date left Have conition specific waiting perios, exclusions or late joiner penalties ever been ipose on ou when appling for ebership of an other eical schee/s? PLEASE x OR STATISTICAL PURPOSES ONLY Ethnic group Do ou want our ebership pack an car: Black Coloure Delivere* Inian White Poste Asian arital Single arrie Divorce Wiowe Coon law partner/ spouse Collecte fro nearest eschee Branch *Deliver Aress uring working hours (ona - ria 08:00A - 17:00P): Postal coe

2 SECTION 3 INTEREDIARY / INANCIAL ADVISER This section ust be signe b the broker/ agent/ aviser if applicable Broker coe SB licence nuber Nae of brokerage Nae of broker/agent/aviser Telephone (W) ular ax E-ail aress Postal aress Phsical aress INANCIAL ADVISER DECLARATION 1. I hereb acknowlege that I a an accreite ehealth inancial Aviser an that I a license b the inancial Services Boar (SB) in ters of the inancial Avisor an Intereiar Services Act 37 of I acknowlege that the applicant has appointe e as his/ her financial aviser an that the applicant is entitle to cancel services at an tie. 3. I confir that the applicant was provie with personal etails, phsical an postal aress an telephone nuber. 4. I acknowlege that a onthl coission of 3% of the total onthl contribution up to a axiu, as legislate fro tie to tie, will be pai to e in ters of the eical Schees Act 131 of 1998 (or as aene). 5. I confir that there has been no aterial isrepresentation of an fact b e an that in the event of aterial isconuct or unlawful conuct, I unertake to refun all onies pai in consequence of such isrepresentation or conuct. 6. The applicant is failiar with the inforation requeste in the application for an all the relevant inforation was provie b the applicant. 7. The applicant is failiar with the inforation relating to the Protection of Personal Inforation (POPI) Act as isplae on 8. The avice an assistance given to the applicant was ipartial an in the best interest of the applicant. 9. The applicant has personall signe the application for. Broker s/ agent s/ aviser s signature SECTION 4... Date DETAILS O YOUR SPOUSE / PARTNER YOU WISH TO REGISTER SPOUSE / PARTNER Surnae aien nae (if applicable) irst nae/s Preferre nae phone nuber E-ail aress to principal eber Gener ID/ passport/ birth certificate nuber Has this epenant ha previous eical ai cover? Nae of previous eical schee If es, please provie etails below ebership nuber Date joine Date left Have conition specific waiting perios, exclusions or late joiner penalties ever been ipose on this epenant on application for ebership of an other eical schee/s? SECTION 5 DEPENDANTS YOU WISH TO REGISTER I confir that I a authorise to provie an isclose the personal inforation of these liste epenants to the Schee for the purpose of receiving benefits an relate services. 1 Ault 2 Chil* Ault to eber Chil* to eber Surnae irst nae/s arital Preferre nae arital ID nuber / passport nuber E-ail aress Gener * Chil epenant = the eber s epenent chil up to the age of 21 or 27 if a full tie stuent Gener

3 SECTION 5 DEPENDANTS YOU WISH TO REGISTER (CONTINUED) 3 Ault Ault to eber 4 Chil* Chil* to eber Surnae irst nae/s arital Preferre nae arital ID nuber / passport nuber Gener E-ail aress Gener * Chil epenant = the eber s epenent chil up to the age of 21 or 27 if a full tie stuent Please note: An epenant turning 21, an over the age of 21, ust furnish either proof of registration fro a full-tie tertiar institution for the current ear or an affiavit. An epenant, other than our biological chilren: supporting legal ocuentation of aoption or foster arrangeent; as well as an affiavit confiring resienc, incoe, eploent an arital of both chil an natural parents. Ault epenants: an affiavit confiring resienc, arital, eploent an incoe. SECTION 6 EPLOYER INORATION This section ust be coplete b our eploer onl if eploer pas our contribution Nae of eploer Eploee nuber Eploent ate Division coe Persal nuber Dept. nae ehealth papoint coe if applicable eical schee start ate 0 1 We confir that the applicant is eploe b us an coence eploent on the above ate Nae of salar ainistrator Copan stap Designation Signature... SECTION 7 BANK DETAILS O PRINCIPAL EBER Date signe Refun of clais an ebit orer instruction I hereb instruct ehealth to electronicall collect contributions an to eposit refuns, using the inforation provie below. I unerstan that transfers cannot be one to an fro creit car accounts. I hereb authorise ehealth to reverse an erroneous transactions an/ or rectif an ET errors without prior notice. te: Direct paing ebers can select either of the following two ates for ebit orer collections. 25th of the onth OR irst working a of the onth Shoul ou iss a paent, ehealth reserves the right to euct on a ifferent ate to collect the isse preiu. Bank charges will appl for rejecte ebit orers. 1. USE THIS ACCOUNT OR ALL TRANSACTIONS USE THIS ACCOUNT OR REUNDS ONLY 2. USE THIS ACCOUNT OR CONTRIBUTION COLLECTIONS ONLY NB: If ou ticke no. 2 on the left then bank etails ust be coplete here. NB. If ou tick this option, then ou ust coplete bank etails for clais refuns on the right. Bank nae Bank nae Branch nae Branch nae Bank branch coe Bank branch coe Tpe of account Cheque Transission Savings Tpe of account Cheque Nae of account holer Nae of account holer Bank account nuber Bank account nuber Transission Savings If onl one bank account is provie, it will be use for both contribution collections an refuns. Please note: Shoul a 3r part pa the contribution on our behalf, the following supporting ocuents are require: A cop of the account holer s ientit ocuent A cop of the account holer s bank stateent Account holer s letter of authorit to the Schee to euct contributions on behalf of the eber. Account/ s holer s signature Date

4 SECTION 8 EDICAL DETAILS Date Nae of eication an osage Have ou been hospitalise? Are ou currentl receiving treatent? Nae an contact nuber of treating P, Dentist or Specialist This section ust be coplete. ailure to isclose inforation is frauulent an a result in ebership not being grante or terination of ebership without refun of contributions pai. Diagnosis Have ou or an of our epenants sought an avice, been iagnose with or been treate for an conitions in the last 12 onths? If es, please provie etails. Nae of beneficiar SECTION 9 NOINATED P DETAILS OR AXIA BASIS, AXIA BASISGRID, AXIA SAVER, AXIA SAVERGRID, AXIA ENTRYSAVER OPTIONS ONLY Shoul this space be insufficient, please attach a separate sheet. If ou or an of our epenants are living with HIV/ AIDS an woul prefer not to isclose the HIV/ AIDS on this for in the interest of confientialit, then please call Ai for AIDS on to register on the HIV/ AIDS Disease anageent Prograe within 90 as of ebership. EBER / DEPENDANT NAE NAE NOINATED P DETAILS PRACTICE NUBER CONTACT DETAILS If ou have selecte axia Basis, axia BasisGRID, axia Saver, axia SaverGRID or axia EntrSaver ou are require to noinate a ail Practitioner (P) fro the ehealth network for ourself an our epenants. Please note that onl visits to a noinate P will be covere on these options. or a list of Ps on the ehealth network visit click on eber tools an ou will fin the P locator button on the right han sie of the page. Alternativel ou can phone the Custoer Contact Centre on for ore inforation. Principal eber Depenant Depenant Depenant Depenant Depenant Depenant

5 SECTION 10 THIRD PARTY POWER O AUTHORITY Shoul ou want to give perission to a thir part to act on our behalf, when ou are unable to, please coplete a separate Thir Part Power of Authorit Consent for. SECTION 11 DECLARATION BY PRINCIPAL EBER 1. I, the unersigne hereb appl for ebership of ehealth eical Schee (the Schee) an also noinate epenants as specifie. 2. I hereb unertake to observe an carr out the provisions of the eical Schees Act 131 of 1998 (the Act) an of the rules of the Schee as aene fro tie to tie. 3. I agree that the Schee shall not be boun in an wa b an representations or unertakings ae or given b an person or agent which is in contraiction with the registere rules of the Schee. 4. I further agree that the coenceent of ebership an the liabilit of the Schee as a result of this application is conitional upon the first contribution being pai an receive b the Schee. In aition, shoul I efault on paent of an subsequent contributions, an fail to ree such efault within the tie perios allowe in the rules, an benefits pai b the Schee on behalf after the receipt of last contribution shall be reverse an paent of these clais shall be for account. 5. I hereb authorise an request an octor or eical professional person, or an other person who a be in possession of, or a hereafter acquire, an inforation concerning / the noinate epenant s health, whether such inforation relates to the past or future, to isclose such inforation to the Schee or its ainistrator an agree that this authorisation an request shall reain in force after / their eaths, as well as prior thereto. I inenif the Schee an its trustees, agents an ainistrator against an clai, of whatsoever nature, which a be ae against the as a result of, or arising out of the isclosure of an test results or eical inforation. 6. I accept an penalties/ waiting perios that a be applie in accorance with the Act. I unerstan that these waiting perios a inclue a 3 onth general waiting perio, a 12 onth waiting perio for pre-existing conitions an, if applicable, a late joiner penalt fee. 7. I hereb authorise the Schee to euct fro salar or an other available funs via ebiting of bank account, all contributions or an other aounts that a becoe ue b e in ters of the Schee s rules. In the event of arrears, I will be responsible for an legal costs that a arise in the recover thereof. 8. It is sole responsibilit as a eber to ensure that the onthl contribution is receive b the Schee. 9. I hereb acknowlege that an creit extene b the Schee to self or epenants whilst a eber of the Schee will becoe paable in full on terination of ebership an that interest a be charge on all aounts ue an owing to the Schee. 10. I acknowlege that the Schee a obtain an inforation regaring self fro an creit bureau, national loans register, South African rau Prevention Service or an other agent I have ealt with, with regars to profile an creit histor. 11. I unerstan that the Schee a provie written notification, to e-ail aress, failing which, financial aviser s e-ail aress as supplie b financial aviser, of changes to its rules. 12. I acknowlege that non-isclosure of an inforation b self or epenants relevant to the assessent of this application shall rener an contracts to which this application relates null an voi, an all contributions pai b e shall be forfeite to the Schee. In such events, the Schee shall be entitle to reclai an aounts which the a have pai to e or an person on or epenants behalf uner such contracts. 13. Shoul there be an aitional inforation require b the Schee which is not receive within 7 as, the Schee will autoaticall suspen the application. 14. I acknowlege that I a not a eber of ore than one eical Schee. 15. I hereb authorise the Schee or an of its noinate representatives to verif an confir bank etails. 16. I acknowlege that a onthl coission of 3% of total onthl contribution up to a axiu, as legislate fro tie to tie, will be pai to the financial aviser in ters of the eical Schees Act 131 of 1998 (or as aene). 17. I agree to provie the Schee with 3 onths written notice to infor ehealth of intention to terinate ebership. 18. I acknowlege that it is responsibilit to notif the Schee of an changes to the facts, or an changes in or epenants state of health, between the ate of signing this application for an the ate when ebership coences. If this is not one before ebership coences, future clais a be rejecte. 19. I hereb confir that I unerstan the various partnership arrangeents (either Designate Service Provier an/ or Preferre Provier) applicable to option an a aware that co-paents an/ or lower reiburseent rates a appl to the non-use of ehealth partners. 20. I eclare that this personal stateent, whether in hanwriting or not is coplete, true an correct an that I have not conceale, withhel or isstate an aterial facts. 21. I consent, with the perission of epenants, that the Schee a collect, use, process, retain an share an epenants personal inforation (PI) for the purpose of proviing eical Schee benefits an anage healthcare services. This inclues the collecting an sharing of personal inforation with the Schee s partners an facilities who are essential to the ainistration an ebership process.* * You can access ore etails on the Protection of our Personal an Health Inforation on When ou accept these ters an conitions ou will allow us to provie our fail with the full range of our eical Schee services. Sanla Realit Access ehealth ebers receive REE Sanla Realit Access ebership a value-ae offering that provies ou with R3 000 cover for our pets in case of an accient through PetSure, as well as up to R5 illion worth of travel insurance through Travel Insurance Consultants (TIC) an up to R5 000 funeral cover. Your Sanla Realit Access ebership is autoaticall activate an terinate with our ehealth ebership. or ore inforation about Sanla Realit Access ou can visit fehealth.co.za/sanla-realit-access/ Please note: Once our Sanla Realit Access ebership is activate, ou will receive onthl counication fro Sanla Realit. You can cancel our Sanla Realit Access ebership at an tie without an effect on our ehealth ebership. Sipl eail info@sanlarealit.co.za In orer to offer, activate an aintain our Sanla Realit Access ebership, ehealth will suppl our personal inforation to Sanla Realit, but not our healthcare inforation. B signing this section, ou agree to the eclaration above an give ehealth our consent to activate our Sanla Realit Access ebership. Signe at. on this.. a of Signature of principal eber... Print nae... Please ail coplete for to: ehealth eical Schee Private Bag X3045 Ranburg 2125 Or fax to: ehealth ebership ax : Ientit nuber Or e-ail to: upate@fehealth.co.za Custoer Contact Centre nuber:

6 Sanla Realit Application for for ehealth eical Ai ebers. Once coplete, please subit with our eical Schee application for. Please tick all boxes where applicable. I hereb confir that the avisor explaine the benefits of the free Realit Access, Realit Core an Realit Health prograes to e an that I have opte to not take up Realit Core or Realit Health. Signature of eber eical Schee ebership nuber: Personal etails Broker etails ull naes: (As per ID) Coplete this section if an intereiar introuce ou to Sanla Realit. Preferre nae: Surnae: Surnae: irst nae: Ientit nuber: Intereiar coe: Eail aress: Contact nuber: Postal aress: Contact nuber: Debit orer authorisation Sanla Realit ebership I hereb authorise that Sanla Realit can use the banking etails provie for eical Schee clais refuns. Please select our ebership option. (Refer to our website or call /9 for ore inforation.) ebership option Single option ail option Realit Health R180 p R230 p Realit Core R80 p R115 p OR Sanla Realit a create a ebit orer instruction base on the inforation inicate below for the specific aount which will be eucte on the first of ever onth unless otherwise requeste. This euction will inicate activation of Sanla Realit ebership an I further agree that the coenceent of ebership an the liabilit of Sanla Realit as a result of this application is conitional upon the first contribution being pai an receive b Sanla Realit. I unertake to infor Sanla Realit of an changes to bank etails an authorise Sanla Realit to verif such etails. (Total SL Debit or Real utures Pt Lt will reflect on our bank stateent for this euction.) te: B selecting the fail option we will autoaticall a our epenants as per our eical Schee. one Saver Car: A the one Saver car to ebership Debit orer inforation: te: There is no car ainistration fee for the first (3) onths, thereafter R55 per onth will appl. ore cars can be orere for fail ebers. Account nae: Bank: Bank coe: Sanla Realit counication options I prefer to receive counication via the following channels: Eail SS Phone ail I woul like to receive inforation about iscounts an special offers available onl to ebers: Perission to use eical Schee inforation Sanla Realit will use our personal inforation (as supplie b our eical Schee) to coplete our Sanla Realit registration. Sanla Realit will keep our personal inforation, as well as the inforation of our spouse an epenant/s, confiential. However, b signing this for, ou agree to the isclosing an use of isclose inforation, incluing that of our spouse an/or epenant/s that ou have provie, in that Sanla Realit a collect, process, store, an share all confiential inforation, as containe in this application an provie to us after the inception of our Sanla Realit ebership. This inforation a be use to: Ainister the Sanla Realit prograe. Provie an services that ou or our spouse or an epenant/s a require. Enable an contracte thir part that requires such inforation to rener a service or provie goos to ou or our spouse or an epenant/s on our Sanla Realit ebership, but onl if such contracte thir part agrees to keep the inforation confiential. Enable an other entit within the Sanla Group, where ou or our spouse or our epenant/s have applie for a prouct, to ainister the prouct. Health ata a be share/utilise in orer to qualif for specific benefits. I hereb agree an give perission. Account nuber: Account tpe: Savings Transission Cheque Signature: I hereb confir that the above inforation is true an correct. I agree that b joining the Sanla Realit prograe I a boun b Sanla Realit s rules as set out b the prograe. or full T&Cs, visit Signe: at Print nae: Print nae: on