Aon Tsc Registration Form – Fill Out and Use This PDF

Date of birth: D D / M M / Y Y Y Y

Date joining Fund: D D / M M / Y Y Y Y

Marital status: ___________________ Date of marriage: D D / M M / Y Y Y Y

Gender:

Male

Female

1. Is the dependant in receipt of an income?

Yes

No

Pension (old age, military or disability):

R ____________________________________________________

Pension (other than above, including an annuity):

R ____________________________________________________

Other (eg, interest and/or dividends on investments):

R ____________________________________________________

Total:

R ____________________________________________________

2.

Is the dependant entirely dependent on you for maintenance and support?

Yes

No

If yes, give details: ___________________________________________________________________________________

3.

Does the dependant reside with you?

Yes

No

If no, give address details: _____________________________________________________________________________

________________________________________________________________________________________________

Select

Initialled

Provide full details for any of the conditions stipulated below in the space provided and

Yes

by

Date

or

ICD-10

principal

of last

attach relevant medical reports to this application.

No

Code

member

treatment

1.

Any disorder of the heart, (eg, rheumatic fever, heart murmur, coronary artery disease,

Y

N

chest pain, shortness of breath or palpitations)?

2.

High blood pressure or disease of the blood vessels or circulatory disorder (eg,

Y

N

cramps during exercise, stroke, high cholesterol, hardening of arteries)?

3.

Any respiratory or lung disease (eg, asthma, bronchitis, persistent cough or

Y

N

tuberculosis)?

4.

Any disorder of the digestive system, gall bladder, pancreas or liver (eg, actual or

Y

N

suspected gastric or duodenal ulcer, recurrent indigestion, hiatus hernia, anal bleeding,

haemorrhoids or jaundice)?

5.

Disease or disorder of the kidney, bladder or reproductive organs (eg, albumin in

Y

N

urine, kidney stones, prostatitis, venereal diseases, infertility or impotence)?

6.

Any nervous or mental complaint (eg, epilepsy, blackouts, anxiety state or depression)?

Y

N

7.

Any type of nerve ailment (eg, loss of sensation, numbness or paralysis)?

Y

N

8.

Ear, eye, nose or throat disorder (eg, discharge, defective vision)?

Y

N

9.

Disorder or disease of skin, muscles, bones, joints, limbs, spine (eg, psoriasis, arthritis,

Y

N

gout, slipped disc or other back trouble)?

10.

Diabetes, hormonal imbalance, glandular or metabolic diseases, thyroid or blood

Y

N

disorders?

11.

Cancer, growth, tumour of any kind?

Y

N

12.

Any other illness, disorder, operation, disability or accident (eg, fractured nose, breathing

Y

N

disorders, mammary hypertrophy (enlarged breasts with associated side-effects,AIDS,

congenital abnormalities, etc)?

13.

Is the dependant, pregnant? State the expected date of confinement: ____________

Y

N

14.

Is the dependant currently undergoing or expecting to undergo any medical, dental or

Y

N

surgical treatment?

15.

Has the dependant received any medical, dental or surgical treatment in the last 12

Y

N

months?

16.

Have any exclusions been imposed by any medical scheme on the dependant?

Y

N

If “YES”, please state details: __________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

17.

Please provide any other relevant information: _____________________________________________________________

______________________________________________________________________________________________

_______________________________________________________________________________________________

Waiting period

Yes / No

From

DD /M M /Y Y

To

DD /MM /Y Y

Reason

Sizwe Medical Fund is administered by Sechaba Medical Solutions (Pty) Ltd.

Condition-speciic waiting period

Yes / No

From

DD /MM /Y Y

To

D D /MM / Y Y

Reason

SECTION 5

TO BE COMPLETED BY PRINCIPAL MEMBER’S EMPLOYER

Date principal member joined scheme: D D / M M / Y Y Y Y

EMPLOYER’S STAMP

Principal member’s date of benefit: D D / M M / Y Y Y Y

Subsidised dependants:

Non-subsidised adult dependants:

Designation:__________________________________________

Email: __________________________________________

Date: D D / M M / Y Y Y Y

Telephone: ( ) __________________________________

Signature of employer official: _____________________________

Date: D D / M M / Y Y Y Y

SECTION 6

DECLARATION BY PRINCIPAL MEMBER

I hereby declare that the information in this declaration is true and correct and agree that any false declaration will render my

application null and void.

Signature of principal member: ____________________________ Date: D D / M M / Y Y Y Y

SECTION 7

ESSENTIAL DOCUMENTS

Are the relevant

documents

attached?

Copy of dependant’s ID:

Yes

No

Birth certificate of child (where ID is not available):

Yes

No

Clinic card for newborn baby (within 30 days of birth to avoid waiting period):

Yes

No

Documentary proof if the dependant is adopted or a foster child:

Yes

No

Marriage certificate when registering a spouse (within 30 days of marriage to avoid waiting period):

Yes

No

Affidavit when registering a common law spouse or partner confirming co-habitation (where applicable):

Yes

No

Dependant’s membership certificate from previous medical aid (where applicable):

Yes

No

Written confirmation that the dependant is a member of the Unemployed Insurance Fund (if unemployed):

Yes

No

Dependant’s proof of taxable income (ie pay slip, SARS IT34 form etc):

Yes

No

Proof of study for dependant/s from the age of 21 years, or affidavit for financially dependent dependant/s,

or doctor’s letter for mentally or physically disabled children.

Yes

No

I give consent for the disclosure of information about me.

Membership number

Medical Scheme

Aon Hewitt 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

Plan type

Tax certificate and tax

Chronic indicator

Date of birth

Medical Savings Account

amounts available

reports

Chronic condition PMB Chronic

ID number

Medical Savings Account choice Scheme Rate

Banking details

condition details Confirmation of

Postal and e-mail

or Cost

Total contribution and

claims paid (excluding amount

Address

Current Medical Savings Account spent

breakdown

and paid from where)

Contact details

Limits

Claims transaction history

Physical address

Waiting period: details

Hospital procedures

Telephone

Wellness benefits

Procedures codes

numbers

Self-payment Gap

Procedures done in doctor’s

Above Threshold Benefit

rooms paid from Hospital Benefit

Yes

No

Acknowledgement of Broker Appointment/Aon Healthcare/2014

1