PO Box Private Bag X3 Century City 7446 t 0860 000 LMS/567 f 021 657 7651 w www.libmed.co.za Thank you for your request to register as an Employer Group 1. It is compulsory for fields marked with * to be completed. 2. Kindly return the following completed and signed form to your Financial Adviser (if applicable) or send to it directly to - email: newgroups@libertyhealth.co.za or fax to 021 657 7661 Please attach a copy of quotation and underwriting terms. SECTION 1 DETAILS OF EMPLOYER GROUP FOR OFFICE USE ONLY Group code L B T New group registration Existing group change EMPLOYER DETAILS Employer name* Registration number ( if applicable) Physical address* Postal code Postal address* Postal code Email address* Proposed registration date of Employer Group Y Y Y Y M M D D Note: The date of commencement of benefits for your employees may differ from your registration date depending on the underwriting terms. Employer contact person* Telephone number* Fax number* Email address* Alternate contact person Telephone number* Fax number* Email address EGA GD 21/09/2015 - V2 1 of 4
EMPLOYER PROFILE Total number of employees* Proposed membership count* Previous medical scheme active employee count Is membership,* a. Voluntary b. Compulsory for all permanent employees (Existing and new) If VOLUNTARY, please state the names of other medical schemes offered to employees If COMPULSORY, please state the terms for non-permanent employees (e.g. probationary, contract). COMPANY STAMP CONTRIBUTION BILLING INFORMATION Name and last name of contact person for billing* (as per ID document) Telephone number* Fax number* Email address* Payroll closing date Y Y Y Y M M D D Note: Monthly billing will be sent via email SPECIAL REQUIREMENTS FOR: To be completed and signed by the consultant or employer* Mailing of membership cards - initial issue only 1. Mail direct to applicant Y N 2. Mail to employer Y N 3. Collect from LMS Y N 4. Courier to BDC/CLC Y N (Please note only physical addresses are allowed for courier) Address for membership card mailing* For attention of Town Address Postal code SECTION 2 WEB REGISTRATION Registering for web services allows you to view the following Group information online: Billing information Member contact details First name and last name (as per ID document) ID number Telephone number Fax number Email address 2 of 4
SECTION 3 CONTRIBUTION ON PAYMENT DETAIL (TO BE COMPLETED BY EMPLOYER GROUP) Please note contributions are payable monthly in advance, no later than the third day following the due date of each month. Please attach a cancelled cheque or bank statement for bank identification purposes. If more than one payer / paypoint, please complete this form per payer / paypoint. Employer name We hereby request and authorise you to draw against our bank account with the bank mentioned below (or any bank or branch to which we may transfer our account) the amount required by you in payment of the monthly contributions due in respect of on the first of the month. If the first of the month falls on a public holiday or Sunday, the deduction will be taken on the first business day thereafter. All such withdrawals from our bank account by the Scheme shall be regarded as authorised by us. We understand that the withdrawals hereby authorised will be processed by computer through a system known as ACB (Automated Clearing Bureau), and we also understand that the details of each withdrawal will be printed on our bank statement or on an accompanying voucher. This authority may be cancelled by us, by giving you thirty (30) days notice in writing. We understand that we shall not be entitled to any refund of amounts, which you withdrew while this authority was in force, if such amounts were legally owing to you. Receipt of this instruction by you shall be regarded as receipt hereof by your bank (whichever it is or may be). We further agree to advise the Scheme in writing of any changes that may occur. THE DETAILS OF OUR BANK ACCOUNT ARE AS FOLLOWS Name of bank* Branch name* Branch code* Account number* Account type* Cheque Transmission Savings Full name of account holder* Signed at on this day of 20 Signature of Authorised Signature of second Authorised SECTION 4 EMPLOYER DECLARATION Name of participating employer* 1. I warrant that the information provided in this application is true, correct and complete and that we have not withheld, concealed or misstated any information. 2. I furthermore confirm that I understand that any underwriting decisions based on this application will become null and void and that the Scheme may impose such new underwriting conditions as it deems fit on our employees, and may furthermore terminate our participation as Employer Group. 3. We accept that cover of our employees will not become operative unless and until any initial contributions required have been received. We agree to pay over the total monthly contributions (Employer and Employee portion), payable in advance, to the Scheme in respect of every applicant by no later than the third day following the contribution due date of each month. 4. We undertake to ensure that the payments made can be reconciled to all contributions due to the Scheme. 5. We understand and agree that all risk and liability in respect of monies submitted to the Scheme (whether by cheque or otherwise),shall remain with us until such time that we can conclusively prove receipt thereof by the Scheme. 6. We agree to pay over the total contribution payable to the Scheme in respect of any applicant when such applicant has left our employ and on whose behalf the Scheme has paid claims after such resignation date, due to our failure to notify the Scheme, in writing and within the notice period as set out in the Scheme s rules, of such resignation. 7. We agree to notify the Scheme of any changes, which would affect applicant or dependant records,within 30 days of such change and per the prescribed procedure and forms. 8. Unless we object in writing within 7 days from receipt of the contribution schedule, it will be deemed that we have accepted the contents of the contribution schedule. 9. We agree to abide by the Rules for termination of Medical Scheme by giving the Scheme three calendar months written notice of our intention to resign as an Employer Groups. In such an event, the membership of all applicants, including continuation and direct paying applicants and pensioners linked to the group shall terminate concurrently. Signed at on this day of 20 Signature of Authorised 3 of 4
SECTION 5 TO BE COMPLETED BY FINANCIAL ADVISER (THIS SECTION IS COMPULSORY) First name and last name Financial Adviser s Commission code Are you accredited with the Council for Medical Schemes? Y N If YES please provide Accreditation number Date accredited Y Y Y Y M M D D Branch name Office telephone Cellphone Alternative number Email address Secondary email address (e.g. Broker Consultant) RECORD OF ADVICE I declare that: 1. I am an accredited adviser in terms of the Medical Schemes Act and licensed by the FSB in terms of the FAIS Act at the date of signing this application form. 2. I have a valid contract with and I have made the client aware of the commission payable by the Scheme. 3. I am responsible for providing the applicant with: my name, physical address, postal address and telephone number. impartial advice that is in his or her best interest. 4. I am accountable for any advice given to the applicant about completion of this application form and joining the Scheme. Signature of Financial Adviser Date Y Y Y Y M M D D 4 of 4
Change of Financial Adviser Form Rules: This form must be completed in full. This form may only be signed by authorised signatories. Individuals: In the case of individual members, only the principal member may act as the authorised person. Employer groups: Private Bag X3, Century City, 7446 t 0860 000 LMS/567 f 021 657 7651 w www.libmed.co.za This form must be accompanied by a letter on the letterhead of the employer to confirm this Financial Adviser appointment, and that all affected members are informed and are in agreement with the appointment. Please attach a list with details of affected members (including membership number/id number and member initials and last name). 1. Details of Newly Appointed Financial Adviser Name of Business/Brokerage Aon South Africa (Pty) Ltd Financial Adviser Main code 200279 Name of Financial Adviser Aon South Africa (Pty) Ltd Financial Adviser Commission code 2. Details of Employer Group (not for individual members) Name of Employer Group Employer Group code(s) Name of Designation 3. Details of Members (only for Individuals) Membership number Initials Last name Identity number Important: 1. With receipt of this appointment form, commission payment to the current Financial Adviser will be suspended according to regulation 28(7) of the Medical Schemes Act. 2. The appointment will be effective from the 1st day of the month if received before or on the 15th of that month. If not received by the 15th, it will be implemented on the 1st day of the following month. 3. The Financial Adviser appointment cannot be backdated. 4. This appointment cancels all previous Financial Advisers appointments. 5505_cfa_0114 1 of2
Authorisation Individuals I/We, to act on my/our behalf in all my/our negotiations with. am/are fully authorised to appoint the abovementioned Financial Adviser I/We authorise the Scheme to share all membership information pertaining to myself and my registered dependants with the newly appointed Financial Adviser so that he/she may render advice and intermediary services to me/us. Please advise if all membership information should: (Please tick applicable box) Include Claims Information Exclude Claims Information Employer Groups I/We, to act on behalf of the Employer Group in all the negotiations with. am/are fully authorised to appoint the above mentioned Financial Adviser I/We, authorise the appointed Financial Adviser so that he/she may render advice and broker services to the members of the Employer Group. Signed at on this day of 20 Signature of Authorised The completed form can be sent to Vcommissions via Fax 021 914 3524 or Email commissions@uniquepay.co.za. Change of Financial Adviser Form 2 of 1
Acknowledgement of appointment Contact us on: 0860 tel arc / 0860 835 272, P.O. Box 1874, Parklands, 2121, www.aon.co.za FSB number: 20555; CMS number: ORG895 I hereby authorise Aon South Africa (Pty) Ltd to be my duly appointed Broker with immediate effect. My ID and membership number I have also been informed of the commission due to Aon, payable by the medical scheme as part of my monthly contribution, is 3% of the contribution to a maximum of R75.00 excl. Vat per month. I have further been issued with a Statutory Notice and Section 13 certificate. Signed at (town or city) on yy/mm/dd Signature Permission to make certain information available to Aon South Africa (Pty) Ltd I give consent for the disclosure of information about me. Membership number Medical Scheme Aon Broker Code Title Initials Surname First name(s) (as per identity document) ID or passport number To clarify this, the following information will be made available: Personal examples Benefit examples Financial examples Medical examples Membership number Date of birth ID number Postal and e-mail Address Contact details Physical address Telephone numbers Plan type Medical Savings Account amounts available Medical Savings Account choice Scheme Rate or Cost Current Medical Savings Account spent Limits Waiting period: details Wellness benefits Self-payment Gap Above Threshold Benefit Tax certificate and tax reports Banking details Total contribution and breakdown Chronic indicator Chronic condition PMB Chronic condition details Confirmation of claims paid (excluding amount and paid from where) Claims transaction history Hospital procedures Procedures codes Procedures done in doctor s rooms paid from Hospital Benefit I hereby also authorise Aon South Africa (Pty) Ltd to provide me with any products that they consider appropriate to me. Yes No Signed at (town or city) on yy/mm/dd Signature Acknowledgement of Broker Appointment/Aon Healthcare/2015 1