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Should you not complete and submit your application to Fedhealth an accredited healthcare representative will contact you to assist with medical scheme and other related products, do you give consent?

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Thank you for applying to be a Fedhealth member. We are reviewing the information you have submitted and we will be communicating with you shortly.

Welcome to Fedhealth, the medical aid that lets you be YOU. We’ve reviewed the information you’ve submitted and are pleased to inform you that your membership application has been accepted. Your membership number is {{submissionResult.memberNumber}}. Please keep an eye on this email address {{$parent.mainMember.contact.email}} as we will be sending you some important information about your plan shortly.

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1. I, the undersigned hereby apply for membership of Fedhealth Medical Scheme (the Scheme) and also nominate my dependants as specified.

2. I hereby undertake to observe and carry out the provisions of the Medical Schemes Act 131 of 1998 (the Act) and of the rules of the Scheme as amended from time to time.

3. I agree that the Scheme shall not be bound in any way by any representations or undertakings made or given by any person or agent which is in contradiction with the registered rules of the Scheme.

4. I further agree that the commencement of my membership and the liability of the Scheme as a result of this application is conditional upon the first contribution being paid and received by the Scheme. In addition, should I default on payment of any subsequent contributions, and fail to remedy such default within the time periods allowed in the rules, any benefits paid by the Scheme on my behalf after the receipt of my last contribution shall be reversed and payment of these claims shall be for my account.

5. I hereby authorise and request any doctor or medical professional person, or any other person who may be in possession of, or may hereafter acquire, any information concerning my/ the nominated dependant’s health, whether such information relates to the past or future, to disclose such information to the Scheme or its administrator and agree that this authorisation and request shall remain in force after my/ their deaths, as well as prior thereto. I indemnify the Scheme and its trustees, agents and administrator against any claim, of whatsoever nature, which may be made against them as a result of, or arising out of the disclosure of any test results or medical information.

6. I accept any penalties/ waiting periods that may be applied in accordance with the Act. I understand that these waiting periods may include a 3-month general waiting period, a 12-month waiting period for pre-existing conditions and, if applicable, a late joiner penalty fee.

7. I hereby authorise the Scheme to deduct from my salary or any other available funds via debiting of my bank account, all contributions or any other amounts that may become due by me in terms of the Scheme’s rules. In the event of arrears, I will be responsible for any legal costs that may arise in the recovery thereof. Should you want to give permission to a third party to act on your behalf, when you are unable to, please complete a separate Third Party Power of Authority Consent form. Income is considered as the highest income earner per household. Income to declare includes, but is not limited to, average monthly earnings over the last 12 months from guaranteed earnings, guaranteed allowances, company contributions and variable pay or commissions from employment (this includes self-employment and informal employment), pension and annuity proceed, interest earned on active and passive investments, rental income from leasing properties and distributions received from a trust. Please note: Should you declare income lower than your actual income, it will be considered fraud and will lead to the immediate cancellation of your membership. What you are required to do: Complete the Income Verification Form and attach all relevant proof of income and other supporting documents requested in each section to avoid any administrative delays. SECTION 11 THIRD PARTY POWER OF AUTHORITY SECTION 10 INCOME VERIFICATION FOR THE MYFED OPTION

8. It is my sole responsibility as a member to ensure that the monthly contribution is received by the Scheme.

9. I hereby acknowledge that any credit extended by the Scheme to myself or my dependants whilst a member of the Scheme will become payable in full on termination of my membership and that interest may be charged on all amounts due and owing to the Scheme.

10. I acknowledge that the Scheme may obtain any information regarding myself from any credit bureau, national loans register, South African Fraud Prevention Service or any other agent I have dealt with, with regards to my profile and credit history.

11. I understand that the Scheme may provide written notification, to my e-mail address, failing which, my financial adviser’s e-mail address as supplied by my financial adviser, of changes to its rules.

12. I acknowledge that non-disclosure of any information by myself or my dependants relevant to the assessment of this application shall render any contracts to which this application relates null and void, and all contributions paid by me shall be forfeited to the Scheme. In such events, the Scheme shall be entitled to reclaim any amounts which they may have paid to me or any person on my or my dependants’ behalf under such contracts.

13. Should there be any additional information required by the Scheme which is not received within 7 days, the Scheme will automatically suspend the application.

14. I acknowledge that I am not a member of more than one Medical Scheme.

15. I hereby authorise the Scheme or any of its nominated representatives to verify and confirm my bank details.

16. I acknowledge that a monthly commission of 3% of my total monthly contribution up to a maximum, as legislated from time to time, will be paid to the financial adviser in terms of the Medical Schemes Act 131 of 1998 (or as amended). Sanlam Reality Access Fedhealth members receive FREE Sanlam Reality Access membership – a value-added offering that provides you with R3 000 cover for your pets in case of an accident through PetSure, as well as up to R5 million worth of travel insurance through Travel Insurance Consultants (TIC) and up to R5 000 funeral cover. Your Sanlam Reality Access membership is automatically activated and terminated with your Fedhealth membership. For more information about Sanlam Reality Access you can visit fedhealth.co.za/Sanlam-reality-access/ Please note: • Once your Sanlam Reality Access membership is activated, you will receive monthly communication from Sanlam Reality. • You can cancel your Sanlam Reality Access membership at any time without any effect on your Fedhealth membership. Simply email info@sanlamreality.co.za • In order to offer, activate and maintain your Sanlam Reality Access membership, Fedhealth will supply your personal information to Sanlam Reality, but not your healthcare information. By signing this section, you agree to the declaration above and give Fedhealth your consent to activate your Sanlam Reality Access membership.

17. I agree to provide the Scheme with 3 months’ written notice to inform Fedhealth of my intention to terminate my membership.

18. I acknowledge that it is my responsibility to notify the Scheme of any changes to the facts, or any changes in my or my dependants’ state of health, between the date of signing this application form and the date when my membership commences. If this is not done before my membership commences, future claims may be rejected.

19. I hereby confirm that I understand the various partnership arrangements (either Designated Service Provider and/ or Preferred Provider) applicable to my option and am aware that co-payments and/ or lower reimbursement rates may apply to the non-use of Fedhealth partners.

20. I declare that this personal statement, whether in my handwriting or not is complete, true and correct and that I have not concealed, withheld or misstated any material facts.

21. I consent, with the permission of my dependants, that the Scheme may collect, use, process, retain and share my and my dependant’s personal information (PI) for the purpose of providing Medical Scheme benefits and managed healthcare services. This includes the collecting and sharing of my personal information with the Scheme’s partners and facilities who are essential to the administration and membership process.*

22. Sanlam Reality Access

22.1. Once your Sanlam Reality Access membership is activated, you will receive monthly communication from Sanlam Reality.

22.2. You can cancel your Sanlam Reality Access membership at any time without any effect on your Fed health membership. Simply email info@sanlamreality.co.za

22.3. In order to offer, activate and maintain your Sanlam Reality Access membership, Fed health will supply your personal information to Sanlam Reality, but not your healthcare information.