Namibia Medical Care
Tel. 061 287 640
PO Box 24792
WINDHOEK, NAMIBIA
MEMBER RECORD AMENDMENT
PLEASE COMPLETE ALL THE APPLICABLE SECTIONS IN FULL
Addition of Dependants Termination of Emploment/Resignation
Removal of Dependants Change Bank Account Details
A. PARTICULARS OF PRINCIPAL MEMBERS (Please print in block letters)
Membership No. ID/Passport No.
Title: Prof/Dr/Mr/Mrs etc. Surname
First Name(s)
Postal Address Street Address
Home - Tel. Code & No. Work - Tel. Code & No.
Cell. Date of Birth D D M M Y Y Y Y
Fax. Marital Status Single Married Divorced Widowed
E-mail Address Date on Which Change will Become Effective
B. ADDITION OF DEPENDANT(S), SPECIAL DEPENDANT(S), ADOPTIONS AND/OR NEWBORN CHILDREN
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 financially
dependent and full-time students at a recognised educational institution.* Attach proof of registration. For more than three(3) dependants, please attach a
list. (If legally adopted, please attach necessary documents). *Recognized educational institutions as per the rules of Namibia Medical Care.
Surname
(if different than principal member)
C. CHANGE OF MARITAL STATUS
If married, attach certified copy of marriage certificate. If divorced, attach certified copy of decree of divorced and a complete copy of statement stating that
the member is responsible for the medical costs of children. In case of death, attach certified copy of death certificate.
Please mark the applicable block with an X Married Divorced Widowed Date of Marriage/Divorce/Death
Surname
First Name(s)
SPOUSE MEDICAL COVER PARTICULARS
Is/was your spouse a member of a registered medical aid fund uninterruptedly for the past two years? Yes No
Name of Present Medical Aid Fund _____________________________________ Membership No.
Period of Membership: From To
Name of Previous Medical Aid Fund ____________________________________ Membership No.
Period of Membership: From To
Was membership subject to any restrictions/exclusions? Yes No If yes, state particulars of restrictions ___________________________
D. REMOVAL OF DEPENDANTS
Please note that in case of divorce, legal documentation is required
Dependant Surname
First Name(s)
ID/Passport No. Effective Date
Reason _____________________________________________________________________________________________________________________
E. DEATH OF MEMBER
Does the widow(er)/eldest dependant wish to continue on the medical aid and become the principal member? Yes No
Effective Date (Please attach certified copy of death certificate)
F. TERMINATION OF EMPLOYMENT/RESIGNATION
Reason _____________________________________________________________________________________________________________________
Resignation/Retrenchment Date ____________________________________________
Would You Like to Continue Membership with NMC? (If you belong to an employer group) Yes No
G. BANK ACCOUNT DETAILS ELECTRONIC FUND TRANSFER OR DEBIT CARD
Name of Account Holder
Account No.
Bank Branch
Type of Account Cheque Savings Transmission 8-Digit Branch Code
ID/Passport No. Date of First Deduction
I authorise Namibia Medical Care to draw from bank account, the premiums (and any stamp duty or short payments) due in terms of the Medical Scheme,
without prejudice to the rights of Namibia Medical Care. I further authorise Namibia Medical Care to increase the amounts 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 repay such amount to me, I will
refund it to Namibia Medical Care. I undertake to notify Namibia Medic Care of any change in respect of my address or bank.
Name _______________________________ Signature of Account Holder _____________________________ Date ______________________
H. UNDERTAKING BY THE APPLICANT
1. I, the undersigned, apply for amendments to my Namibia Medical Care membership, as indicated above 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 the membership and that shall be warranted as true and complete; and that my membership shall be void if any information
should be inaccurate or incomplete, in which events all moneys paid towards the membership shall be forfeited to Namibia Medical Care, and all benefits
paid shall immediately be repayable to Namibia Medical Care.
My membership shall not be amended 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 date of occurrence set by Namibia Medical Care for the commencement of
the change in membership or the date which the amendments as applied for in this document are accepted by Namibia Medical Care, shall give
Namibia Medical Care the right to reconsider the amendments and to propose new terms of acceptance or to declare the membership null in which event
all moneys 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.
2. I irrevocably give my consent to my medical doctor, person or organisation, who may possess, 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, also 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
by me to Namibia Medical Care.
Signed at _____________________________________ on the ________________________ Day of ____________________ 20 _____
Signature of Witness ____________________________ Date _________________________ Signature of Applicant _________________________
Approval by Company ___________________________ Date _________________________
(Signature of Company Official)
If Married: Spouse Title:
Prof/Dr/Mr/Mrs/Miss etc.
Full First Names Sex M/F Occupation ID/Passport No. Date of Birth
