Particulars of Medical Scheme Membership
Particulars of Medical Scheme Membership
Particulars of Medical Scheme Membership
Surname
First Name
Middle Name
Maiden Name
Date of Death Marital Status Married Unmarried Widow/er Divorced Life Partner
Surname
First Name
Middle Name
Maiden Name
ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID AND THE MEMBER OR
PENSIONER AND COMMISSIONER OF OATHS MUST INITIAL THIS PAGE.
3.
4.
5.
6.
7.
8.
* 1-Spouse 2-Child 3-Disable 4-Student 5-Life Partner 7-Mother 8-Father 9-Grandchild A-Sister B-Brother
Employer Name
Employer Name
Employer Name
Employer Name
OR
2. OPTION B - Gratuity Payment (Once-off cash amount)
Subject to 12 months continued membership of a registered medical fund on the last day of service
only if less than:
- 15 Years in respect of retirement
- 10 years in respect of medical discharge
ALL PAGES OF THIS FORM MUST BE COMPLETED IN ORDER FOR THIS FORM TO BE VALID AND THE MEMBER OR
PENSIONER AND COMMISSIONER OF OATHS MUST INITIAL THIS PAGE.
Service record in government departments or related institutions. All periods of service must be furnished:
I certify that all particulars in this form are true and correct.
Designation
Surname of Employer
Representative
Tel No
Fax No
E-Mail address
K) CERTIFICATION PARTICULARS
Date Date