Fillable APPLICATION FOR MEMBERSHIP

Fill Online, Printable, Fillable, Blank APPLICATION FOR MEMBERSHIP Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

APPLICATION FOR MEMBERSHIP

On average this form takes 83 minutes to complete

The APPLICATION FOR MEMBERSHIP form is 5 pages long and contains:

  • 4 signatures
  • 84 check-boxes
  • 275 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
APPLICATION FOR MEMBERSHIP
(Read Addendum notes before completing form)
PLEASE COMPLETE ALL THE APPLICABLE SECTIONS IN FULL
Applicant’s Status Principal Member Additional Dependant Special Dependant
A. BENEFIT OPTION
Topaz Topaz Plus
Opal
Jade Ruby Sapphire
Diamond Emerald Emerald Plus Amber Amber Plus
(hospital cover only) (hospital cover with optional
day-to-day benefits
(hospital cover only) (hospital cover with optional
day-to-day benefits)
Membership Start Date
D D M M Y Y
Are you applying as an individual
(Private Member)?
Or as a member of an Employer Group?
(Please Complete Section K)
B. PARTICULARS OF PRINCIPAL MEMBER (Please print in block letters)
TITLE (Prof/Dr./Mr./Mrs. etc.) SURNAME
FIRST NAME
DATE OF BIRTH
D D M M Y Y
GENDER
M F
ID/PASSPORT NO.
NATIONALITY MARITAL STATUS
SINGLE MARRIED WIDOWED DIVORCED
OCCUPATION
(Indicate if you are a Pensioner)
GROSS MONTHLY INCOME (N$)
(Compulsory for Opal)
POSTAL ADDRESS STREET ADDRESS
POSTAL CODE
TEL. (HOME)
TEL. (WORK)
CELL NO.
FAX:
EMAIL ADDRESS
(Principal Member)
EMAIL ADDRESS
(Spouse (if applicable))
FOR OFFICE USE ONLY
UNDERWRITING DECISIONS
WAITING PERIOD
ON D-D BENEFITS
Yes No
EXCLUSIONS
CONFINEMENT
WAITING PERIOD
Yes No
MEMBERSHIP NUMBER OPTION
REGISTRATION
DATE:
D D M M Y Y
PREMIUM (N$) PAYMENT METHOD
CASH DEBIT ORDER EFT GROUP
BENEFIT DATE ON DAY-TO-DAY
BENEFITS
D D M M Y Y
INDIVIDUAL
MEMBERSHIP
GROUP
CODE
GROUP
NAME:
PROCESSING DATE
D D M M Y Y
CLERK
(INITIALS)
CONTROL OFFICER/CLERK
(INITIALS AND DATE)
Namibia Medical Care
P.O. Box 24792
Windhoek, Namibia
Tel. (061) 287 6000
Email: enquiries@methealth.com.na
FAXED APPLICATION
FORMS ARE NOT
ACCEPTABLE
C. EMPLOYER DETAILS
COMPANY NAME
ADDRESS
TEL.
Fax.
D. PARTICULARS OF PREVIOUS MEDICAL COVER
Were/Are you a member/dependant of a Namibian registered medical aid fund for the past two years? If ‘yes’, please attach a certificate(s)
of membership from your current/previous medical aid fund (a membership card is not sufficient).
Yes No
NAME OF CURRENT MEDICAL AID FUND MEMBERSHIP NO.
PERIOD OF MEMBERSHIP: FROM
D D M M Y Y
TO:
D D M M Y Y
NAME OF PREVIOUS MEDICAL AID FUND MEMBERSHIP NO.
PERIOD OF MEMBERSHIP: FROM
D D M M Y Y
TO:
D D M M Y Y
Was membership subject to any restrictions/exclusions?
Yes No
If yes, state particulars of restrictions
E. PARTICULARS OF DEPENDANTS
Husband, wife and children under 21 years, who are unmarried and not in full employment. Children up to 25 years may be included if they are full-time students
at a recognised educational institution*. Attach proof of registration. Please attach a list for more than five (5) children. (If legally adopted, please attach the
necessary documents). If surnames differ from that of Principal Member, please provide documentary proof of relationship.
*Recognised educational institution as per the rules of Namibia Medical Care.
Dependants First Name Surname
(if different from principal member)
Gender
M/F
Occupation ID/Passport Number
D.O.B ID/Passport No.
Spouse
1
st
Child
2
nd
Child
3
rd
Child
4
th
Child
5
th
Child
F. STATE OF HEALTH
TO BE SUPPLIED BY MEMBER/APPLICANT (COMPULSORY)
Please provide the name and address of your general practitioner, dentist, as well as any specialist you may have consulted recently.
Dentist
Doctor
Specialist
Tel.
Tel.
Tel.
Please complete the questionnaire by placing an X in the answer box that corresponds to your response.
Have you, your spouse or any dependants ever experienced any of the following:
1. Any disorder of the heart (e.g. angina, heart attack, heart murmur, rheumatic fever, coronary artery disease, chest pain, shortness of
breath, palpitations, congenital disorders, etc.)?
Yes No
2. High blood pressure or disease of the blood vessels or circulatory disorder (e.g. high cholesterol, stroke, thrombosis, cramps in the
calves with exercise or walking etc.)?
Yes No
3. Any respiratory or lung disease/disorder (e.g. asthma, bronchitis, tuberculosis, persistent cough)? Yes No
4. Any disorder of the digestive system, gall bladder, pancreas or liver (e.g. hiatus hernia, recurrent indigestion, suspected gastric or
duodenal ulcer, rectal bleeding, piles or jaundice or have you ever had a gastroscopy)?
Yes No
5. Disease or disorder of the kidney, bladder or reproductive organs (e.g. protein in the urine, kidney stones, nephritis, prostatitis, cystitis
or sexually transmitted disease)?
Yes No
6. Diabetes, thyroid or other glandular or blood disorders (e.g. anaemia or bleeding disorders, leukaemia, haemophilia)? Yes No
7. Eye, ear, nose or throat disorder (e.g. defective vision, hearing loss, ear discharge, recurrent tonsillitis, hoarseness, retinitis pigmentosa,
glaucoma)?
Yes No
8. Nervous or mental complaint (e.g. epilepsy, blackout, paralysis, anxiety state or depression, chronic headaches, fits, fainting, multiple
sclerosis, brain impairment)?
Yes No
9. Disorder or disease of the skin eruption, (e.g. porphyria, psoriasis, dermatitis, muscles, bones, joints, limbs or spine, e.g. rheumatism,
arthritis, gout, slipped disc or other back condition)?
Yes No
10. Any tropical disease (e.g. bilharzia, malaria, brucellosis)? Yes No
11 . Cancer, a growth or tumor of any kind? Yes No
12. Any other illness, disorder or operation, disability or accident, (INCLUDING MOTOR VEHICLE ACCIDENTS) which required medical,
radiological, surgical, pathological investigations, or have you ever been hospitalised?
Yes No
13. Do you or any of your dependants have any physical (including dental), abnormality, deformity, handicap or defect, whether congenital
or as a result of an accident, disease or some other cause? For dental system (poor closure of jaws, implants, orthodontic, periodontic
or maxillofacial surgery).
Yes No
14. Are you or your dependants currently undergoing or expecting to undergo any medical, dental, or surgical treatment? Yes No
15. Are you or any of your dependants pregnant? If yes, state expected date of delivery. Yes No
If the answer to question 15 is YES, please answer the following questions:
16. Did you or any of your immediate family e.g. mother, dependants, sister experience any complications with previous pregnancies? Yes No
17. Are there any complications or health problems detected in you or your immediate family ‘s current pregnancy or that of the unborn
baby?
Yes No
18. Does any member of your (or your spouse’s) immediate family e.g. parents, brothers or sisters suffer from diabetes, heart disease, high
blood pressure, raised cholesterol, mental disease, porphyria or any other disease?
Yes No
19. Did you experience any health problems or show signs and symptoms of health problems in the last 3-months before applying for
membership?
Yes No
20. Has your weight or the weight of your spouse/dependant changed more that 5kg in the last 12 months? If so, why? Yes No
21. Are you or your dependants smokers? Yes No
22. Are there any addictions we should be aware of? Yes No
23. Height & weight (Principal member)
Height
Weight
Height & weight (Spouse)
Height
Weight
Height & weight (child 1)
Height
Weight
Height & weight (child 2)
Height
Weight
Height & weight (child 3)
Height
Weight
Height & weight (child 4)
Height
Weight
Height & weight (child 5)
Height
Weight
If you have answered ‘yes’ to any of the above questions please provide the full details below:
Question
No.
Beneficiary
(Name of Person)
Illness or
condition
Date and duration of
the illness or condition
Date and nature of
treatment received
medical or surgical
result of treatment
Name of doctor,
hospital or institution
Treatment
recommended: likely
date and duration of
treatment
If more space is needed, please attach list.
G. CHRONIC MEDICATION
*An application form for the CHRONIC MEDICATION BENEFIT must be
completed before any benefit can be received. (Form obtainable from the
NMC website, www.nmcfund.com or your nearest Client Services Office.)
Do you or any of your dependants use chronic medication? Yes
No
Beneficiary
Diagnosis
Prescribed Medication
Strength
Dosage Period medication used
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
From
D D M M Y Y
To
D D M M Y Y
H. YOUR BANKING ACCOUNT DETAILS (Required for refunds to be deposited directly into account)
ACCOUNT HOLDER’S NAME
ACCOUNT NO.
BANK TYPE OF ACCOUNT: CURRENT
SAVINGS
BRANCH NAME BRANCH CODE
Please note:
• a bank confirmation letter is required; and
• no post office savings accounts are allowed
I. DEBIT ORDER (Required for authorisation of deduction of monthly contributions from bank account) (ONLY FOR INDIVIDUAL MEMBERSHIP)
ACCOUNT HOLDER’S NAME
ACCOUNT NO.
BANK TYPE OF ACCOUNT: CURRENT
SAVINGS
BRANCH NAME BRANCH CODE
ID NUMBER
DATE OF LAST DEDUCTION
D D M M Y Y
I authorise Namibia Medical Aid to draw from my bank account (wherever it may be), the premiums (and any stamp duty or short payments) due to it in terms of the
policy from time to time and authorise my bank to effect payment of such increased amount upon receipt of written notice from Namibia Medical Care stating the
increased amount and the date from which it is payable. This authorisation is to remain in force until cancelled by me by giving written notice to Namibia Medical
Care.
I agree that I am not entitled to recover any amount drawn from my account by means of this debit order and that should my bank repay such amount to me, I will
refund Namibia Medical Care. I undertake to notify Namibia Medical Care of any change in respect of my address or bank.
NAME SIGNATURE OF ACCOUNT HOLDER DATE
click to sign
signature
click to edit
J. UNDERTAKING BY THE APPLICANT
1. I, the undersigned, apply for the membership of Namibia Medical Care and agree that all answers and information contained in this application and all
documents which, in Namibia Medical Care’s opinion, are relevant to the risk and which are signed or will be signed by me, shall be the basis of my
membership and that they shall be warranted as true and complete; and that my membership shall be void if any information should be inaccurate or
incomplete, in which event all the money paid towards the membership shall be forfeited to Namibia Medical Care and all benefits paid shall immediately be
payable to Namibia Medical Care.
My membership shall not commence unless Namibia Medical Care specifically notifies me in writing of their acceptance of the risk; and any deterioration or
change of the state of my health or the health of my dependants before the due date or the occurrence set by Namibia Medical Care for the commencement
of the membership or the date on which this application is accepted by the Namibia Medical Care, or the date of receipt of the first subscription whichever is
the latest date, shall give Namibia Medical Care the right to reconsider the application and to propose new terms of acceptance or to declare the membership
null and void, in which event all the money paid towards this membership before Namibia Medical Care receives notice of such a change shall be forfeited to
Namibia Medical Care and benefits paid shall immediately be repayable to Namibia Medical Care. I hereby agree to abide by the Rules of Namibia Medical
Care as required by Act 23 of 1995 and approved by NAMFISA.
2. I irrevocably give my consent to my medical doctor, person or organisation, who may posses, or may come in possession of any information regarding my
health or the health of my dependants, to disclose this information to Namibia Medical Care, including after my death.
3. I give my consent to my employer in the case of group membership to deduct from my salary and pay Namibia Medical Care all amounts that may be due to
Namibia Medical Care.
Signed at on the Day of 20
WITNESS DATE APPLICANT’S SIGNATURE
K. EMPLOYER’S DECLARATION CONCERNING GROUP SCHEME APPLICANT
I/We declare that
was appointed as a full-time employee on
D D
M M Y
Y
and is entitled to membership of the group scheme number
from
D D
M M Y
Y
The monthly subscription of N$
will be paid from
D D M M Y Y
COMPANY OFFICIAL’S SIGNATURE DATE EMPLOYER’S STAMP
ADDENDUM TO NAMIBIA MEDICAL CARE APPLICATION FOR MEMBERSHIP FORM (for all applicants)
Thank you for applying for membership with our fund. To ensure your relationship with Namibia Medical Care remains satisfactory for the duration of your
registration as a member, it is important that you comply with the following requirements:
1. The application form must be COMPLETED IN FULL, i.e. all information requested must be provided. Please do not leave any blank spaces, or delete, without
reading and providing required information.
2. Section F of the application is important, thus all required information must be provided. ANY INFORMATION PROVIDED THAT IS NOT TRUE/INCOMPLETE/
NOT DISCLOSED, could have SERIOUS REPERCUSSIONS in your future association with the Fund.
3. No medical examinations, etc. are necessary at this stage of your application, but we encourage you to submit copies of your medical reports to support
your application.
4. Please note that all day-to-day benefits (Category B), for members joining as individuals, will be pro-rated for the first 3 months.
5. The Fund Rules stipulate that a member will be classified as a member of an “EMPLOYER GROUP” if his/her membership is derived from the participation in
the FUND of an EMPLOYER who employs at least twenty EMPLOYEES. An “EMPLOYER GROUP” will be classified as a voluntary group if at least 70% of the
employees of the group who are eligible to belong to a medical aid fund, join NMC.
6. If you are NOT joining the Fund on 1 January you will have PRO-RATA day-to-day benefits.
7. No benefits are available for any exclusions/restrictions that have been placed on the principal member and/or his/her dependants from date of registration.
These exclusions/restrictions will be first communicated to the principal member for acceptance, prior to registration.
8. DO NOT RESIGN FROM YOUR PRESENT MEDICAL AID FUND until you receive formal communication that your application has been approved.
NAME SIGNATURE OF ACCOUNT HOLDER DATE
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

APPLICATION FOR MEMBERSHIP

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document