1 of 4EGA GD 21/09/2015 - V2

Liberty Medical SchemeEmployer Group Application Form

Liberty Medical Scheme PO Box Private Bag X3Century City 7446t 0860 000 LMS/567 f 021 657 7651w www.libmed.co.za

Thank you for your request to register as an Employer Group

1. It is compulsory for fields marked with * to be completed.

2. Kindly return the following completed and signed form to your Financial Adviser (if applicable) or send to it directly to Liberty Medical Scheme - email: newgroups@libertyhealth.co.za or

fax to 021 657 7661

Please attach a copy of quotation and underwriting terms.

SECTION 1 – DETAILS OF EMPLOYER GROUP

FOR OFFICE USE ONLY

Group code L B T

New group registration Existing group change

EMPLOYER DETAILS

Employer name*

Registration number ( if applicable)

Physical address*

Postal code

Postal address*

Postal code

Email address*

Proposed registration date of Employer Group Y Y Y Y M M D D

Note: The date of commencement of benefits for your employees may differ from your registration date depending on the underwriting terms.

Employer contact person*

Telephone number* Fax number*

Email address*

Alternate contact person

Telephone number* Fax number*

Email address

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EMPLOYER PROFILE

Total number of employees* Proposed membership count*

Previous medical scheme active employee count

Is membership,* a. Voluntary b. Compulsory for all permanent employees (Existing and new)

If VOLUNTARY, please state the names of other medical schemes offered to employees

If COMPULSORY, please state the terms for non-permanent employees (e.g. probationary, contract).

COMPANY STAMP

CONTRIBUTION BILLING INFORMATION

Name and last name of contact person for billing*(as per ID document)

Telephone number* Fax number*

Email address*

Payroll closing date Y Y Y Y M M D D

Note: Monthly billing will be sent via email

SPECIAL REQUIREMENTS FOR:

To be completed and signed by the consultant or employer*

Mailing of membership cards - initial issue only

1. Mail direct to applicant Y N 2. Mail to employer Y N

3. Collect from LMS Y N 4. Courier to BDC/CLC Y N

(Please note only physical addresses are allowed for courier)

Address for membership card mailing*

For attention of

Town

Address

Postal code

SECTION 2 — WEB REGISTRATIONRegistering for web services allows you to view the following Group information online:

• Billing information

• Member contact details

First name and last name(as per ID document)

ID number

Telephone number Fax number

Email address

Capacity/Designation

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SECTION 3 – CONTRIBUTION ON PAYMENT DETAIL (TO BE COMPLETED BY EMPLOYER GROUP)Please note contributions are payable monthly in advance, no later than the third day following the due date of each month.

Please attach a cancelled cheque or bank statement for bank identification purposes. If more than one payer / paypoint, please complete this form per payer / paypoint.

Employer name

We hereby request and authorise you to draw against our bank account with the bank mentioned below (or any bank or branch to which we may transfer our account) the amount required by you in payment of the monthly contributions due in respect of Liberty Medical Scheme on the first of the month. If the first of the month falls on a public holiday or Sunday, the deduction will be taken on the first business day thereafter.

All such withdrawals from our bank account by the Scheme shall be regarded as authorised by us.

We understand that the withdrawals hereby authorised will be processed by computer through a system known as ACB (Automated Clearing Bureau), and we also understand that the details of eachwithdrawal will be printed on our bank statement or on an accompanying voucher.

This authority may be cancelled by us, by giving you thirty (30) days notice in writing. We understand that we shall not be entitled to any refund of amounts, which you withdrew while this authority was inforce, if such amounts were legally owing to you. Receipt of this instruction by you shall be regarded as receipt hereof by your bank (whichever it is or may be).We further agree to advise the Scheme in writing of any changes that may occur.

THE DETAILS OF OUR BANK ACCOUNT ARE AS FOLLOWS

Name of bank*

Branch name* Branch code*

Account number*

Account type* Cheque Transmission Savings

Full name of account holder*

Signed at ____________________________________________________________________________________________ on this ___________________________________________________________ day of _________________________________________________ 20 _____________

First name and last name of Authorised Signatory

Signature of Authorised Signatory

Capacity/Designation

First name and last name of Authorised Signatory

Signature of second Authorised Signatory

Capacity/Designation

SECTION 4 — EMPLOYER DECLARATIONFirst name and last name of Authorised Signatory

Capacity/Designation

Name of participating employer*

1. I warrant that the information provided in this application is true, correct and complete and that we have not withheld, concealed or misstated any information.

2. I furthermore confirm that I understand that any underwriting decisions based on this application will become null and void and that the Scheme may impose such new underwriting conditions as it deems fit on our employees, and may furthermore terminate our participation as Employer Group.

3. We accept that cover of our employees will not become operative unless and until any initial contributions required have been received. We agree to pay over the total monthly contributions (Employer and Employee portion), payable in advance, to the Scheme in respect of every applicant by no later than the third day following the contribution due date of each month.

4. We undertake to ensure that the payments made can be reconciled to all contributions due to the Scheme.

5. We understand and agree that all risk and liability in respect of monies submitted to the Scheme (whether by cheque or otherwise),shall remain with us until such time that we can conclusively prove receipt thereof by the Scheme.

6. We agree to pay over the total contribution payable to the Scheme in respect of any applicant when such applicant has left our employ and on whose behalf the Scheme has paid claims after such resignation date, due to our failure to notify the Scheme, in writing and within the notice period as set out in the Scheme’s rules, of such resignation.

7. We agree to notify the Scheme of any changes, which would affect applicant or dependant records,within 30 days of such change and per the prescribed procedure and forms.

8. Unless we object in writing within 7 days from receipt of the contribution schedule, it will be deemed that we have accepted the contents of the contribution schedule.

9. We agree to abide by the ‘Rules for termination of Medical Scheme’ by giving the Scheme three calendar months’ written notice of our intention to resign as an Employer Groups. In such an event, the membership of all applicants, including continuation and direct paying applicants and pensioners linked to the group shall terminate concurrently.

Signed at ____________________________________________________________________________________________ on this ___________________________________________________________ day of _________________________________________________ 20 _____________First name and last name of Authorised Signatory

Signature of Authorised Signatory

Capacity/Designation

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SECTION 5 – TO BE COMPLETED BY FINANCIAL ADVISER (THIS SECTION IS COMPULSORY)

First name and last name

Financial Adviser’s Commission code

Are you accredited with the Council for Medical Schemes? Y N

If “YES” please provide Accreditation number Date accredited Y Y Y Y M M D D

Branch name Cellphone

Office telephone Alternative number

Email address

Secondary email address (e.g. Broker Consultant)

RECORD OF ADVICE

I declare that:1. I am an accredited adviser in terms of the Medical Schemes Act and licensed by the FSB in terms of the FAIS Act at the date of signing this application form.2. I have a valid contract with Liberty Medical Scheme and I have made the client aware of the commission payable by the Scheme.3. I am responsible for providing the applicant with:

• my name, physical address, postal address and telephone number. • impartial advice that is in his or her best interest.

4. I am accountable for any advice given to the applicant about completion of this application form and joining the Scheme.

Signature of Financial Adviser Date Y Y Y Y M M D D

Liberty Medical SchemeChange of Financial Adviser Form

1 of25505_cfa_0114

Liberty Medical SchemePrivate Bag X3, Century City, 7446

t 0860 000 LMS/567 f 021 657 7651w www.libmed.co.za

Rules:

• This form must be completed in full. • This form may only be signed by authorised signatories.

• Individuals: • In the case of individual members, only the principal member may act as the authorised person.

• Employer groups: • This form must be accompanied by a letter on the letterhead of the employer to confirm this Financial Adviser appointment, and that all affected members are informed and are in agreement with

the appointment. • Please attach a list with details of affected members (including membership number/ID number and member initials and last name).

1. DEtaIls of NEwly appoINtED fINaNcIal aDvIsERName of Business/Brokerage financial adviser Main code

Name of financial adviser financial adviser commission code

2. DEtaIls of EMployER GRoup (Not foR INDIvIDual MEMBERs)Name of Employer Group Employer Group code(s)

Name of signatory Designation

3. DEtaIls of MEMBERs (oNly foR INDIvIDuals)Membership number Initials last name Identity number

Important:

1. With receipt of this appointment form, commission payment to the current Financial Adviser will be suspended according to regulation 28(7) of the Medical Schemes Act.2. The appointment will be effective from the 1st day of the month if received before or on the 15th of that month. If not received by the 15th, it will be implemented on the 1st day of the following month.3. The Financial Adviser appointment cannot be backdated.4. This appointment cancels all previous Financial Advisers appointments.

Aon South Africa (Pty) Ltd

Aon South Africa (Pty) Ltd

200279

2 of 1Change of Financial Adviser Form

authoRIsatIoN

Individuals

I/We, am/are fully authorised to appoint the abovementioned Financial Adviserto act on my/our behalf in all my/our negotiations with Liberty Medical Scheme.

I/We authorise the Scheme to share all membership information pertaining to myself and my registered dependants with the newly appointed Financial Adviser so that he/she may render advice and intermediary services to me/us.

Please advise if all membership information should: (Please tick applicable box)

Include Claims Information

Exclude Claims Information

Employer Groups

I/We, am/are fully authorised to appoint the above mentioned Financial Adviserto act on behalf of the Employer Group in all the negotiations with Liberty Medical Scheme.

I/We, authorise the appointed Financial Adviser so that he/she may render advice and broker services to the members of the Employer Group.

Signed at on this day of 20

Signature of Authorised Signatory

the completed form can be sent to vcommissions via fax 021 914 3524 or Email commissions@uniquepay.co.za.

Contact us on: 0860 tel arc / 0860 835 272, P.O. Box 1874, Parklands, 2121, www.aon.co.za FSB number: 20555; CMS number: ORG895

Acknowledgement of appointment I hereby authorise Aon South Africa (Pty) Ltd to be my duly appointed Broker with immediate effect.

My ID and membership number

I have also been informed of the commission due to Aon, payable by the medical scheme as part of my monthly

contribution, is 3% of the contribution to a maximum of R75.00 excl. Vat per month. I have further been issued with a

Statutory Notice and Section 13 certificate.

Signed at (town or city) on yy/mm/dd

Signature

Permission to make certain information available to Aon South Africa (Pty) Ltd

I give consent for the disclosure of information about me.

Membership number

Medical Scheme Aon 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 examplesMembership number Date of birth ID number Postal and e-mail Address Contact details Physical address Telephone numbers

Plan type Medical Savings Account amounts available Medical Savings Account choice Scheme Rate or Cost Current Medical Savings Account spent Limits Waiting period: details Wellness benefits Self-payment Gap Above Threshold Benefit

Tax certificate and tax reports Banking details Total contribution and breakdown

Chronic indicator Chronic condition PMB Chronic condition details Confirmation of claims paid (excluding amount and paid from where) Claims transaction history Hospital procedures Procedures codes Procedures done in doctor’s rooms paid from Hospital Benefit

I hereby also authorise Aon South Africa (Pty) Ltd to provide me with any products that they consider appropriate to me.

Yes No

Signed at (town or city) on yy/mm/dd

Signature

Acknowledgement of Broker Appointment/Aon Healthcare/2015 1