BonCap income declaration form 2016 P.O. Box 1101, Florida Glen 1708 Call Centre Fax (011)

Transcription

1 This fm is only to be used by members who have selected the BonCap Option. Broker House Name: Aon SouthAfrica (Pty) Ltd BonCap income declaration fm 2016 P.O. Box 1101, Flida Glen 1708 Call Centre Fax (011) Instructions Complete this application fm in black ink Print clearly using capital letters Mark with an X where necessary Please attach the documents required to this fm This fm must be completed after reading through the Bonitas Product Brochure. Please note: We cannot process your application if it is incomplete, increct you have not attached the crect documents to it. Members on BonCap: Subject to a BonCap GP BonCap Netwk hospital. Section 1: Main member s details Please fill in your details below. Ensure that all fields are marked clearly can be read easily. Date of birth: Tax number: Marital status: Gender: M F Please select the income-b that applies to your gross monthly income: R500 less R501 to R6 550 R6 551 to R R to R R me Please note: If you do not send through proof of income you will be defaulted to the highest income b. Members on BonCap may only be treated by a BonCap netwk doct hospital. Section 2: Spouse/partner s details Please fill in your spouse/partner s details below. Ensure that all fields are marked clearly can be read easily. Date of birth: / / Tax number: Marital status: Gender: M F Please select the income-b that applies to your spouse s gross monthly income. R500 less R501 to R6 550 R6 551 to R R to R R me 1

2 Section 3: Contribution payer s details This section must only be completed f members whose premiums will be paid by a third party, f example if your premiums are paid by your parents children. The third party must fill in their infmation below sign the declaration. Date of birth: / / Tax number: Relationship to main member: Gender: M F Bank name: Branch code: Branch name: Name of accountholder: Account number: Account type: I instruct Bonitas to electronically collect contributions by debit der, using the infmation above. I underst that transfers cannot be done to from credit card accounts. I also irrevocably authise Bonitas to adjust any increct transactions / crect any electronic transfer funds errs without pri notice. Contribution payer s signature: Section 4: Declaration of income BonCap contributions are income-based. We will look at the higher gross monthly income of you your spouse/partner to determine your contribution. Please fill in your infmation below. Description of income Salary wages Commission other rewards Pensions annuities Rental income Trust distributions Government grants UIF payments Interest on investments Subsidy of any kind Maintenance Other income Main member R per month Spouse/partner R per month Total income R R We also require the documents in the table below to be attached to this fm f you your spouse. If the required documents are not submitted with the application fm declaration of income fm, you will be defaulted to the highest income-b. Broker House Name: Aon South Africa (Pty) Ltd 2

3 If you Earn a monthly salary Get paid weekly / ftnightly Wages We need Your latest payslip Letter from employer/company that confirms your income Your bank statements f the last 3 months (showing your monthly income other 4 latest Weekly payslips 2 latest fthnightly payslips Letter from employer/company that confirms your income Checklist of Documents supplied P.O. Box 1101, Flida Glen 1708 Call Centre Fax (011) newapplications@bonitas.co.za Your bank statements f the last 3 months (showing your monthly income other Earn Commission Your latest 3 months payslips 3 month commission statements Your bank statements f the last 3 months (showing your monthly income other Are self-employed Copy of an IT34A/SARS notice of assessment (current) Letter from an external audit/accounting firm confirming your income Your bank statements f the last 3 months (showing your monthly income other Unemployed Mins (including Primary Secondary Education) UIF Statement Letter from the Department of Labour confirming your unemployment status Retrenchment letter/dismissal letter Your bank statements f the last 3 months (showing your monthly income other If you do not have a bank account, the Scheme requires confirmation from the Funder of your Contributions in writing indicating such. The relationship of the Funder is required to be disclosed to the Scheme. The Scheme requires confirmation from the Funder of your Contributions in writing indicating such. The relationship of the Funder is required to be disclosed to the Scheme. Full Time Student (Tertiary Education) Feign Student Proof of registration from your tertiary institution (student card only will not be accepted) A copy of your passpt Proof of registration from your tertiary institution Proof of payment f 12 month premiums 3

4 If you Feign National Permanently Disabled Temparily Disabled Earn a State Pension Earn any Other Pension We need A copy of your passpt A copy of wk permit A copy of your contract reflecting your contract period monthly income Your bank statements f the last 3 months (showing your monthly income other A Full Medical Rept A Disability grant letter Your bank statements f the last 3 months (showing your monthly income other A copy of your IT34A/SARS Notice of assessment A Full Medical Rept A Disability grant letter Your bank statements f the last 3 months (showing your monthly income other A Most recent pension statement Pension income letter (not older than 6 months) Your bank statements f the last 3 months (showing your monthly income other A copy of your IT34A/SARS Notice of assessment A Most recent pension statement Pension income letter (not older than 6 months) Your bank statements f the last 3 months (showing your monthly income other Checklist of Documents supplied Please note: Bank statements submitted must clearly show the money earned being deposited into the account. Section 5: Acknowledgement consent By signing this fm, you declare that the infmation given is true crect that you give Bonitas Medical Fund permission to verify the declared income of you your spouse/partner. Declaring income lower than your actual income is fraud. This will lead to the immediate cancellation of your membership you will not be able to join Bonitas Medical Fund again. Main member s signature: Date: Spouse/partner s signature: Date: Broker House Name: Aon South Africa (Pty) Ltd 4

5 ou will need to appoint Aon as your healthcare broker in der to access your employer subsidy BROKER APPOINTMENT I Membership number: ID number: hereby appoint Aon South Africa Pty Ltd Broker code AON001M16 intermediary. - AON CONSULTING SANDTON to be my health care I am fully aware that with the signing of this Broker Appointment, I hereby acknowledge accept that the appointed broker will receive a monthly commission of 3%, capped at R75.00 excluding VAT. This commission is paid by the Medical Scheme I as the Member have no liability to the Broker in respect of payment receipt of such commissions. I underst that the broker has to render the following services to me: Hling enquiries on Products Services of the Scheme: Regarding 1. Benefit structures offered furnish advice on best suited choice 2. Premiums to be paid on each product / parts thereof 3. Exclusions related to specific circumstances 4. Enrolment conditions applying to specific situations 5. Service provider details where necessary 6. Rules of Medical Scheme 7. Administrative Procedures to be followed Continuous updating on: 1. The Scheme s products benefits 2. The Scheme s Rules where applicable, procedures In exceptional circumstances upon specific request, confirmation of the following: 1. claims received 2. claims status 3. claims paid 4. claims payment date 5. Enquiries on additional products of the Scheme Contact details of member Tel: Fax: Postal Address: Member signature Date NB: Please attach a signed copy of the membership card / recent medical aid statement