Particulars of Medical Scheme Membership

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NATIONAL TREASURY GEPF USE ONLY - GEPF STAMPS

Government Employees
Pension Fund (GEPF)
BAR CODE
MEDICAL SCHEME
MEMBERSHIP – Z583
Private Bag x63 Tel No : (+27) (0) 12 319 1911
34 Hamilton Street
Pretoria Fax No : (+27) (0) 12 326 2507
Arcadia Pretoria Call Centre : (+27) (0) 12 319 1000
SOUTH AFRICA
0001 E-mail : [email protected]
WebSite : www.gepf.co.za
PARTICULARS OF MEDICAL SCHEME MEMBERSHIP
This form enables the GEPF to successfully process the application for continued Medical assistance or to
indicate a change in Medical Scheme Particulars.
COMPULSORY ATTACHMENTS: See section B.
A) TYPE OF APPLICATION - Please select only one option
1. Application for continued Medical Assistance after Retirement/Death in Service (Resolution 3
of 1999 and Resolution 1 of 2006) (Compulsory items: B,D,E,F,G,H,I,J and K. C in case of death)
2. Continued Membership of Medical Scheme - Change of Medical Scheme Particulars
(Compulsory items: B,D,E,F,G,H and K)
3. Application of Widow / Widower for continued Membership of Medical Scheme
(Compulsory items: B,C,D,E,F,G and K)
B) COMPULSORY ATTACHMENTS
All copies of ID documents should be clear, and should not be older Only applicable to Type 2 Applications:
than 6 months.
Copy of last Salary
1. Certified copy of ID of the main member of the Medical scheme.
Advice
2. Proof of all the dependants registered on your medical scheme.
Completed Z894 - Bank
Certified copy of ID and or birth certificate.
particulars
3. Membership Certificate from your medical scheme.
Service Certificate
4. Member Death Certificate (if applicable)
5. Please include previous medical scheme certificate(s).
C) PERSONAL PARTICULARS OF DECEASED MEMBER Pension Number
Surname
First Name
Middle Name
Maiden Name
Title Init D.O.B ID No
Date of Death Marital Status Married Unmarried Widow/er Divorced Life Partner
D) PERSONAL PARTICULARS OF APPLICANT Pension Number
Surname
First Name
Middle Name
Maiden Name
Title Init D.O.B ID No

Income Tax No Married Unmarried Widow/er Divorced Life Partner
Marital Status
E) CONTACT PARTICULARS OF APPLICANT

Postal Address Residential Address
Postal Code Postal Code

Tel
No Cell No
E-Mail
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.
Member/Pensioner initial Commissioner of Oaths initial
Z583 - MEDICAL SCHEME MEMBERSHIP November 2007 Revision

Pension Number
F) PARTICULARS OF DEPENDANTS - For any dependant registered on your medical scheme

Surname First Name ID No / Passport number Type *
1.
2.
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
G) PARTICULARS OF MEDICAL SCHEME

The Medical Scheme details refer to the current and new medical scheme
Medical Scheme Name
Medical Scheme Number
Would you like to continue your membership? Yes No
Date of Benefit Membership Commencement Date
H) PARTICULARS OF PREVIOUS MEDICAL SCHEME

Date on which membership was terminated
Medical Scheme Name

Medical Scheme Number
I) CHOICE FOR MEDICAL BENEFIT UPON RETIREMENT / DEATH

A single choice between Option A or Option B is compulsory - Please indicate clearly
1. OPTION A - Continued State Subsidised Membership

Subject to 12 months continued membership of a registered medical fund on the last day of service
and previous government service exceeding:
- 15 Years in respect of retirement
- 10 years in respect of medical discharge
Employer Name
Start Date End Date
Employer Name
Start Date End Date
Employer Name
Start Date End Date
Employer Name
Start Date End Date
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.
Member/Pensioner initial Commissioner of Oaths initial

Pension Number
J) TO BE COMPLETED BY THE LAST EMPLOYER DEPARTMENT

State Contribution to member medical aid on last day of service
Last day of employment
Reason for retirement
Service record in government departments or related institutions. All periods of service must be furnished:
From To Department or Institution
I certify that all particulars in this form are true and correct.
Official Date Stamp of Employer Signature 1
Designation
Surname of Employer
Representative
Tel No
Fax No
E-Mail address
K) CERTIFICATION PARTICULARS
I declare that all the particulars furnished Commissioner Stamp

on this form is true and correct. Declared and signed before me
Signature or Thumbprint of Member Commissioner of Oaths
Date Date

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NATIONAL TREASURY GEPF USE ONLY - GEPF STAMPS

C) PERSONAL PARTICULARS OF DECEASED MEMBER Pension Number

Title Init D.O.B ID No

D) PERSONAL PARTICULARS OF APPLICANT Pension Number

Title Init D.O.B ID No

E) CONTACT PARTICULARS OF APPLICANT

Postal Code Postal Code

Member/Pensioner initial Commissioner of Oaths initial

Z583 - MEDICAL SCHEME MEMBERSHIP November 2007 Revision

F) PARTICULARS OF DEPENDANTS - For any dependant registered on your medical scheme

G) PARTICULARS OF MEDICAL SCHEME

Medical Scheme Name

Medical Scheme Number

Would you like to continue your membership? Yes No

Date of Benefit Membership Commencement Date

H) PARTICULARS OF PREVIOUS MEDICAL SCHEME

Medical Scheme Name

I) CHOICE FOR MEDICAL BENEFIT UPON RETIREMENT / DEATH

1. OPTION A - Continued State Subsidised Membership

Start Date End Date

Start Date End Date

Start Date End Date

Start Date End Date

Member/Pensioner initial Commissioner of Oaths initial

Z583 - MEDICAL SCHEME MEMBERSHIP November 2007 Revision

J) TO BE COMPLETED BY THE LAST EMPLOYER DEPARTMENT

Last day of employment

Reason for retirement

From To Department or Institution

Official Date Stamp of Employer Signature 1

I declare that all the particulars furnished Commissioner Stamp

Signature or Thumbprint of Member Commissioner of Oaths

Z583 - MEDICAL SCHEME MEMBERSHIP November 2007 Revision

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