Service Provider Application Form

Service Provider Application Form Applying for registration for: Tick appropriate block EMS Fill in sections: A B C F G ROAD Fill in sections: A D E F H Europ Assistance Worldwide Service South Africa (pty) LTD HOME Fill in sections: A D E F H Service Provider Management Department Tel: 0119919212 FUNERAL Fill in sections: A D E F Fax: 0862984134 TAKE ME HOME Fill in sections: A D E F H spadmin@europassistance.co.za Practice Number: PART A Applicants Details Business Registered Business Address Postal Address Details Title MR MRS Ms Dr & Surname Call Centre / 24 Hour number Office Tel No Fax Number Alternative number 1 Alternative number 2 BEE Status Email address 1 Email Address 2

PART B Physical Addresses of Branches / Bases & Level of care Branch address 1 2 3 4 Pls Provide HPCSA cards of all ALS Staff EMS SERVICES Specialist equipment ICU: YES NO NEONATAL: YES NO and dedicated vehicle Air Ambulance: YES NO Number of vehicles Number of Ambulances : Number of Response cars : Air Ambulance: Make of aircraft: Medical Officer Supervising Medical Officer : YES NO Respective names and HPCSA Registration Numbers Emergency Care Practitioner (B.Tech EMC) : Paramedic i.e. CCA/Dip.AEC : Qualification of Staff Emergency Care Technician (ECT) : Ambulance Emergency Assistant : Basic Ambulance Assistant : NUMBERS PART C DECLARATION: I, the undersigned, hereby declare that the above information is valid and correct. I undertake to advise Europ Assistance SA SP Management Department of any changes to my practice profile. In the event that such changes may occur, I further declare that I will abide by the following: in terms of regulation 5(f) of the Medical Schemes Act (Act 131 of 1998), it is a requirement that all registered providers of healthcare services include diagnostic codes on accounts or statements that may be used to claim benefits from medical schemes and administrators. I declare that I will comply with the regulation 5(f) of the General Regulations to the Medical Schemes Act and will use ICD-10 Codes for this purpose. In terms of regulation 5(h) of the Medical Schemes Act (Act131 of 1998), it is a requirement that all registered providers of healthcare include the full cost of accounts or statements that may be used to claim benefits from medical schemes and administrators. I declare that I will comply with the requirements of regulation 5(h) of the General Regulations to the Medical Schemes Act requiring the full cost of rendering a service to be included on all accounts. I decare that I am registered with the relevant South African Statutory professional body. I declare to comply with all obligations in terms of the Income Tax Act. I acknowledge that a practice number does not necessarily guarantee payment by medical scheme or medical scheme administrator. Signature Position Date

PART D Services Offered Roadside Assistance Jump Start Tyre change Fuel Delivery Towing First Tow Second tow Trade Tow Accident Tow First Tow Second tow Trade Tow Heavy Duty / Commercial Tow Fuel Delivery Jump Start Locksmith Lowbed Mech Repairs Towing Tyre Change Recovery unit Towing Electrical Assist Electrical repairs Installations Gate/Garage Motor Generators Pool Motors Stoves Maintenance Plumbing Assist Plumbing Drain Rods Geysers Drain Machines Leak detection Plumbing Maintenance Locksmith Home Auto Smart Key Keys Cut Safes Doors Double Lock Take Me Home Drink & Drive We Drive Chauffeur Services Appliance White Appliances Black Appliances Refrigeration Air-conditioning Repairs Funeral Services Repatriation Travel Services and Arrangements Embalming Caskets and Tomb Stone Specialised Services Venue - Chapels or After-service Cremation Companies Vehicles Roadside vehicles Rollbacks Motorbike Trailers Courtesy Vehicles * We require photos of your vehicles STAFF Drivers Plumbers Electricians Locksmiths Technicians * We require proof of qualifiction of staff

PART E DECLARATION: I / We declare that the information stated in this Europ Assistance Service Provider Application Form are true and hereby do declare I know of no reason to dispute as such. Further I undertake to advise Europ Assistance SA SP Management Department of any changes to my company profile. : Signature: Position: Witness: Signature: Date: PART F Banking Details Bank Account Number Branch Code Account Type Company Insurance Yes No Type of Insurance Insurance Value R Broker Person Number Accountant Address Bookkeeper Associations Yes No Required Documentation: EMS

Part G Tax certificate Accountant Letter Proof of Accounting Package Sample invoice & Remittance advise ALS/ECP HPCSA registration BHF Certificate BEE Certificate Sample PRF & Invoice Required Documentation: Road & Home Part H Company CK or PTY documents Tax certificate Accountant Letter Sample invoice & Remittance advise Drivers License/PDP Vehicle License/s Trade/Artisan certificate Sample tow slip Training Course/s BEE Certificate