Underwritten & Administered by Health & Accident Underwriting Managers (PTY) Ltd 1994/002308/07. / An Authorised Financial Services Provider - FSP 376

www.healthacc.co.za / Insured by Short Term Insurer Compass Insurance Co Ltd FSP 12148

This product is designed for persons on a Medical Aid Scheme to assist with specific costs resulting from in-hospital treatment that have not been paid to their full extent by the Medical Aid Scheme (subject to the parameters and terms and conditions of the elected GAP option). To determine whether this product is suitable for you, please discuss it with your broker and read the FAQs provided to your broker.

I confirm that I have read the Frequently Asked Questions: I have attached a copy of the Medical Aid Certificate in support of this application form:

Broker name: Inception date required:

Broker consultant: Broker code:

Medical aid scheme & option: Medical aid number:

PLEASE SELECT THE APPLICABLE OPTION:

Universal Gap Cover Universal Gap Plus Cover

Younger than 65

Older than 65

Younger than 65

Older than 65

Universal Gap Cover Premium R174.00 R452.00 Universal Gap Plus Cover Premium R231.00 R476.00

Crisis Assistance Facility R12.11 R12.11 Crisis Assistance Facility R12.11 R12.11

Universal Marketing Fee R10.09 R10.09 Universal Marketing Fee R10.09 R10.09

Total Monthly Contribution R196.20 R474.20 Total Monthly Contribution R253.20 R498.20

Additional Overage Child Dependant premium - R70.00 per dependant over 23 - 30 years R R Additional Overage Child Dependant premium -

R70.00 per dependant over 23 - 30 years R R

PERSONAL DETAILS

Surname: Title: Male Female First Names:

Postal Address:

Postal Code:

Residential Address:

Postal Code:

Telephone Number (home): Telephone Number (work):

Cellular Number: Fax Number:

Employer Name: Email Address:

Occupation: Married Divorced Single Widowed ID Number: Passport Number:

Date of Birth: Citizenship I Nationality:

Passport Number: Signature:

FAMILY MEMBERS TO BE COVERED

First Names ID No. or Passport No. & Date of Birth Gender M/F

Spouse (only 1 nominated spouse per

policy) or Child

State if living with

you

Spouse Yes No

Child Yes No

Child Yes No

Child Yes No

Child Yes No

Child Yes No

Universal Gap / Gap Plus Cover

Application Form - 2020Health And Accident | FSP376 | Administered by Health & Accident Underwriting Managers (Pty) Ltd

22 Stiglingh Rd, Rivonia | PO Box 324, Rivonia 2128 | Tel. (011) 234 7333 | Fax (011) 234 7351 | Email: policyadmin@healthacc.co.za | www.healthacc.co.za

I have attached proof of banking details for the account to be debited for this policy:

SPECIFIC HEALTH QUESTIONS

State whether you or your dependants have ever been treated or are currently receiving treatment for any of the following , but not limited to, illnesses:1. Blood disorders, e.g. anaemia, bleeding disorders, haemophilia, leukaemia Yes No2. Cancer growths or tumours whether benign or malignant Yes No3. Cardiovascular disorders, e.g. heart conditions, chest pain, coronary artery disease, high blood pressure, varicose veins, poor circulation Yes No4. Endocrine disorders, e.g. high cholesterol, diabetes, thyroid abnormalities Yes No5. Eye related disorders, e.g. glaucoma, blindness, eye surgery, retinitis pigmentosa, cataracts Yes No6. Gastro-intestinal disorders, e.g. recurrent indigestion, ulcers, bowel disorders, gallbladder disorders, liver disorders Yes No

7. Gynaecological and obstetrical disorders, e.g. ectopic pregnancy, caesarean section, fibroids, endometriosis, menstrual irregularities, abnormal pap smear Yes No

8. Musculo-skeletal disorders, e.g. arthritis, back problems, gout, osteoporosis, joints, e.g. knee, shoulder, etc. Yes No9. Neurological disorders, e.g. epilepsy, muscular weakness, stroke, brain or spinal cord disorders, chronic fatigue Yes No

10. Psychological disorders, e.g. anxiety, depression, stress, panic attacks, alcohol or drug dependency, attention deficit Yes No11. Renal (kidney) disorders, e.g. blood in the urine, kidney stones, recurrent infections, kidney failure Yes No12. Respiratory disorders, e.g. asthma, allergic rhinitis, chronic bronchitis, emphysema, tuberculosis Yes No13. Skin disorders, e.g. eczema, psoriasis, melanoma, skin cancer Yes No

14. State whether you or any of your dependants have received medical advice or treatment for any infectious diseases e.g. gonorrhoea, genital herpes, syphilis, Tuberculosis, hepatitis or tested positive for HIV(AIDS) Yes No

15. Are you or any of your dependants currently pregnant? If so, please specify the expected date of delivery Yes No

16. Do you or any of your dependants expect to receive any treatment, or surgery in the next 12 months and do you or your dependants expect to be, or are currently hospitalised? Yes No

17. Do you or any of your dependants currently receive or expect to receive treatment with any type of medication for longer than 3 months? Yes No

IF ‘YES’ ANSWERED TO ANY OF THE QUESTIONS ABOVE, PLEASE SUPPLY FULL DETAILS BELOW.

Question Number Applicant Full details

(including details of disorder, date diagnosed, nature and duration of treatment and the consulting doctor’s contact details)

If the space provided is insufficient, please attach additional information to this application.N.B. Any misinterpretation or non-disclosure of material medical or factual information will render all benefits granted by Health & Accident Underwriting Managers (Pty) Ltd null and void. In addition, any payment made due to such actions will be required to be repaid by the insured Person to Health & Accident Underwriting Managers (Pty) Ltd

Return to your Broker initialed, signed and completed application together with a copy of your current Medical Aid Membership Certificate.

PLEASE GIVE THE NAME & ADDRESS OF YOUR GENERAL PRACTITIONER AS WELL AS ANY SPECIALIST YOU MAY HAVE RECENTLY CONSULTED

Doctor’s Name: Medical Practitioner’s Name:

Address: Address:

How long has your G.P. been in attendance? When did you last consult your Specialist?

Telephone Number: Telephone Number:

Please debit my bank account: Cheque Savings Transmission Name of Account Holder: Name Of Bank:

Branch: Branch code:

Account no:

DECLARATION

Please read carefully. Failure to disclose material information can result in immediate cancellation of your policy

1. Failure to disclose material information or the provision of incorrect information can result in immediate cancellation of my Policy.

2. I declare that any false statement in the above application or the non-disclosure of any material information will render the Policy and the cover afforded thereby null and void.

3. I hereby authorise any Hospital, Physician or any other person who has attended or examined me or any other Insured’s covered by the Policy to furnish to Health & Accident Underwriting Managers (Pty) Ltd or their authorised representative all information with respect to any illness, injury or medical history, consultation, prescription or treatment and or medical copies of all hospital or medical history, consultation, prescription, or treatment and copies of all hospital or medical records.

4. I hereby acknowledge that any benefits paid out on my / Insured’s Behalf, not covered by the terms and conditions of the policy cover, will be refunded to the Health & Accident Underwriting Managers (Pty) Ltd.

5. I hereby apply for the insurance cover and agree that any benefits due will be payable provided all relevant premiums are paid to date.

6. I accept benefits will be payable directly into my authorised bank account.7. Note: This policy includes consent to the disclosure of private underwriting

and claims information per the applicable policy terms and conditions.8. All insured persons must appear on the Insured Person’s medical aid certificate.

Signature of Applicant Date

Return to your Broker initialed, signed and completed application together with a copy of your current Medical Aid Membership Certificate.

PAYMENT METHOD AUTHORITY - ALL BLOCKS MUST BE COMPLETED

Please note: if the collection falls over the weekend or on a RSA public holiday, collection will be on the next ordinary business day.

I authorise Health & Accident Underwriting Managers (Pty) Ltd (or its appointed agents) to debit our account the monthly payment and administration fees required in terms of the cover chosen. We understand this will apply for each month or until cancelled by us in writing.

I/We understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African banks. I also understand the details of each withdrawal will be printed on my bank statement. Such must contain a number which must be included in the said payment instruction and if provided to me should enable me to identify the Agreement. This number will reflect the policy number issued to me on fulfilment of this agreement.Mandate

I /We acknowledge that all payment instruction issued by you shall be treated by my/our above-mentioned bank as if the instructions had been issued by Me/Us personally.

Cancellation of authorityI/We agree that although this Authority and Mandate may be cancelled by Me/Us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which may have been withdrawn while this Authority was in force, if such amounts were legally owing to you.

Cancellation of insuranceThis insurance may be cancelled by the Insured Person giving one calendar months’ notice in writing to Health & Accident Underwriting Managers (Pty) Ltd.

AssignmentI/We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement this Authority and Mandate cannot be assigned to any third party.

Signed at ____________________________________ on this ____________________day of ____________________

Account holder’s signature: __________________________________________________(Signature as used for operating on the account)

Debit order start date: Broker:

Debit order date: Debit order reference:1st COMPA