Namibia Medical Care
Reg. No. 90/334
P.O. Box 24792, Windhoek , Namibia
Tel (061) 287 6226
Fax (061) 287 6176
APPLICATION FOR ADDITIONAL BENEFITS
EX GRATIA APPLICATION FORM
1. TO BE COMPLETED BY APPLICANT
Details of Member
Surname
Title Initial(s) Date of Birth D D M M Y Y Y Y
Postal Address Postal Code
Telephone No. (H) (W)
Fax Cell No.
E-mail
Medical Aid Fund
Medical Aid No.
Details of Patient
Surname
Title Initial(s) Date of Birth D D M M Y Y Y Y
2. MEDICAL REPORT TO BE COMPLETED BY MEDICAL PRACTITIONER
Diagnosis: (Please attach detailed motivational letter & photographs where applicable.)
Medical history
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Treatment and medication required (Please attach detailed quotation from medical practitioner or service provider.)
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Doctor’s Name ________________________________ Signature __________________________________________
Practice No. __________________________________ Date ______________________________________________
3. GENERAL
Have you ever considered upgrading to an option to suit your requirements? Yes No
If no, state full reasons:
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Have you previously applied for ex gratia? Yes No
If yes, please give details:
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COMPULSORY
Please attach the following:
1. Proof of income: copy of salary slip/pension income/other
a. Main member
b. Spouse
c. Cohabitant partner (As per Fund rule description)
2. Copies of all accounts related to the ex gratia application
IMPORTANT
1. Ex gratia requests are never paid at 100% of the outstanding amount; the percentage ex gratia allocated is managed according to the
ex gratia criteria.
2. This application will not be submitted to the Committee should any section be incomplete.
3. Ex gratia payments may not be considered in advance of any excess in benefit arising.
4. Ex gratia payments may only be made by the Committee at its absolute discretion provided it is satisfied that extreme hardship would
otherwise be imposed upon the member.
I, the undersigned, hereby certify that the information stated in this documents is complete, true and correct.
Signature of Applicant ________________________________ Date _______________________________________
