Member No: Date of Birth (dd/mm/yyyy): / /

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1 c l a i m f o r s i c k n e s s b e n e f i t f o r m ( d e c l a r a t i o n b y m e m b e r ) The Professional Provident Society Holdings Trust No. 312/2011 (PPS) is a Registered South African Trust. Professional Provident Society Insurance Company Limited Reg. No. 2001/017730/06 (PPS Insurance). PPS Insurance is an authorised Financial Services Provider Licence No PART A MEMBER DETAILS IMPORTANT: Please read attached information leaflet prior to completion of this form. Correct completion of this form will aid the prompt processing of your claim. Member No: Date of Birth (dd/mm/yyyy): / / Surname: Initials: ID No: Postal Address: Cell: Tel (W): Code: Fax: PART b health questions 1. Please state the medical condition for which you are claiming: 2. If this claim is due to an injury, please provide details: Date of injury: / / 3. If you were hospitalised, please provide: Name of hospital: Date admitted: / / Date discharged: / / 4. Female policyholders only: Are you pregnant? Y N If YES: Estimated date of delivery: / / 5. Please state the occupation which you were practising immediately prior to the period for which you are claiming. Are you employed Full-time? or Part-time? Please indicate in the table below how often you are required to perform the mentioned tasks during your work day Daily Occupational Activities Percentage (%) of the Relevant Activity as Part of Your Normal Working Day Driving as an integral part of your professional duties Standing Walking on even terrain Walking on uneven terrain Bending / stooping Use of both hands as an integral part of your professional duties Fine coordination Sitting / administrative Lifting objects 10-20kg Lifting objects >20kg 6. Were you on leave prior to your claim? Y N If yes, specify type of leave (eg. annual leave, maternity, paternity, study, special leave) Leave period?: / / to / / 7. Are you currently practising your profession aboard? Y N 8. I, the above-named, declare that: I did not carry out ANY of my usual professional duties (Total Sickness) from: / / to / / I was able to carry out SOME of my usual professional duties (Partial Sickness) from: / / to / / 1 Please fax or your completed form to +27 (11) or claims@pps.co.za

2 PART b health questions (cont.) Details of your usual professional duties that you performed prior to this claim: Date resumed duties: On a Partial basis / / On a Full-time basis / / 9. Please state the name(s) of the doctor(s) and/or dentist(s) that attended to you, in respect of this current incapacity. It may be necessary for our claims area to contact them for further information. Practitioner s Surname & Initials Consultation Date Tel Fax 10. Please state which practitioner declared you incapacitated: PART c self-employed State the name of your practice/business: How long have you been self-employed? If you are a partner in the business, what is your percentage share in the business? % Is your business based at your home? Y N Gross Professional Income (Annual income from professional fees and nett income from trading activities; including all overhead expenses): (Minus) Actual Expenses (Expenses incurred in the running of the business that are not remunerated to the professional. Expenses that will terminate if the business is sold or closed): (Equals) Personal Income (Gross Professional Income minus Actual Expenses): PART d SALARIED EMPLOYMENT State the name of your employer: State your annual income as: Annual Total Cost to Company (Annual salary plus all fringe benefits): (Plus) Performance Bonus (Average over the last 3 years): (Equals) Total Gross (Professional income): PART e banking details for sickness benefit via eft When payment of the claim is to be paid into a bank account other than from which premiums are collected, please complete the details below: (Please attach a cancelled cheque or bank statement stamped by the bank if payment is to be made to a 3rd party) Name of Account Holder: Name of Bank: Branch Name: Account No: Branch Code: Type of Account: Current Savings Cheque Transmission Indemnity Please take note that PPS will not be held liable for incorrect payments, if the information received is incorrect. 2 Please fax or your completed form to +27 (11) or claims@pps.co.za

3 PART f declaration I specifically authorise PPS Insurance to communicate any requirements to my financial advisor which may entail providing information regarding my current medical condition. Y N Financial Advisor s Name: I (Full name): certify that all the above information is true and correct. Financial Advisor s ID Number: I authorise PPS Insurance to: a) Obtain from any person or institution, any information which PPS deems necessary to assess an insurance risk or to consider a claim. b) Share with other insurers and their representation body any information in the possession of PPS Insurance, either directly or through a database operated by, or for insurers as a group, at any time. c) Disclose any information to the PPS Holdings Trust, subsidiaries, affiliates, Profmed or other persons provided that it is necessary to properly underwrite, manage or service the policy, policy assets or myself. PPS Insurance may be required to disclose your informaton to regulatory or government agencies. d) Obtain credit information from any person or institution. PPS Insurance will always do its utmost to prevent any unauthorised disclosure of your personal information. PPS will adhere to any laws governing the protection of (and access to) personal information; and will not use your information for any purpose not provided for in your Policy Contract and in this Part F. Signed at (Place): on this day of 20 Signature: 3 Please fax or your completed form to +27 (11) or claims@pps.co.za

4 PROCEDURE FOR CLAIMING SICKNESS BENEFITS The payment of sickness benefits is subject to certain claim procedures and in order to process claims promptly, members are requested to follow the correct procedure. For more information, please find the "How to claim" document in the FAQ tab on Claims for sickness benefits must be made on the prescribed PPS claim forms. Please ensure that all details are filled in correctly as incorrect information or failure to answer any of the questions will result in a delay in the processing of your claim. Three forms must be submitted before a claim can be processed: A: Declaration by the Medical Doctor/Dentist, B: Declaration by the Member A. Declaration by Medical Doctor/Dentist 1. Your treating medical practitioner/dentist must complete this form. 2. The initial consultation date must be within the first 7 days of the start of theclaim period and monthly thereafter. The most recent consultation dates should be stated. 3. Total/partial sickness benefits definitions: Total is when the member is totally unable to attend to any of his/her usual professional duties in or out of the office. Partial is when a member is able to perform some but not all of his/her usual professional duties in or out of the office. You are entitled to claim partial sickness benefits only after a minimum of a Total sickness claim for a period of seven consecutive days. Usual Professional Duties are defined as those occupational tasks which you carry out as part of your occupation prior to claim. This may include administrative duties or tasks for example attending to electronic communication. 4. Claim extending beyond one month: In order to claim for a sickness benefit a monthly declaration by doctor or dentist is required. This implies that you must have had a consultation each month during the period of claim with your attending medical practitioner.deviation from this policy is only allowed in cases where PPS have agreed to this in writing. B. Declaration by Member 1. You must complete this form. 2. The start and end dates of your claim period must be in accordance with the period booked off by your treating doctor/dentist. Page 1 OCTOBER 2014

5 3. Post-dated claim forms are not accepted. Claims will only be assessed up to the date signed provided that it was signed at least 7 days after the inception date of the claim period. Claim forms should be submitted at the end of the claim period or on a monthly basis with ongoing claims. 4. If an accident is the cause of your claim, you must provide us with details on how the accident occurred. General 1. You must be totally unable to attend to any of your usual professional duties for a minimum period of seven days before you are entitled to claim. 2. The doctor/dentist (not the member) should complete the Declaration by Doctor Form. 3. When submitting ongoing claim, each monthly claim form should be dated from the first date to the last date of the month being claimed, e.g and the following month Hospital cover, where applicable, can only be paid on receipt of the admission sheet or the hospital account showing admission and discharge date. Hospital cover will only be paid for hospitalization of four or more consecutive days including the admission and discharge dates. 5. Post-dated claim forms are not accepted. 6. Average days: PPS will assess sickness claims based on the expected average days recuperation time for a particular health condition. The average days paid for a condition is based on standard medical practice. Should further recuperation time be required due to e.g. complications, the reason must be indicated on the Declaration by Doctor Form and the likely date for returning to work stated. Should the claim period extend beyond that expected further information may be requested. 7. Claims submitted after one month from date of onset of illness will only be considered with written motivation, including sufficient information to assess the late submission. Proof of consultation dates will be required as well as a report from the attending medical specialist. 8. PPS can, in terms of the PPS Provider Policy, request submission of weekly consultations and claim forms if deemed appropriate in the circumstances of a sickness claim. 9. Please allow eight working days before querying the progress of your claim. Page 2 OCTOBER 2014

6 10. In some instances additional information may be requested from either yourself or medical practitioner/s. Kindly take note that this could delay the finalisation of the claim. You and/or your doctor/dentist will be notified by /fax/post if additional information is required. PPS Claims: Fax: Queries: The Professional Provident Society Holdings Trust No IT 312/2011 (PPS) is a Registered South African Trust Professional Provident Society Insurance Company Limited Reg. No 2001/017730/06 (PPS Insurance) PPS Insurance is an Authorised Financial Services Provider Licence No Page 3 OCTOBER 2014