Member Acknowledgement Declaration

Please read the declarations below carefully. These contain acknowledgements of fact that may impact on your rights. These declarations must be read in conjunction with the rules of CompCare Medical Scheme (hereafter referred to as “the Scheme”), and the Medical Schemes Act No. 131 of 1998 (hereafter referred to as “the MSA”), and all these provisions shall be binding on you and your dependants. Please tick the boxes to acknowledge that you have read each declaration:

1. I, the undersigned hereby apply for membership of CompCare Medical Scheme and agree that all answers and information relating to my dependants and I, contained in this application completed by me or by any other person / s will be the basis of the proposed agreement.

2. I warrant that the contents of this application are true, correct and complete, whether the information is relating to myself or any of my listed dependants. No cover will be granted unless CompCare Medical Scheme specifically notifies me in writing of their acceptance of the risk, or on receipt of a valid membership card. Failure to comply with any of the terms and conditions of the agreement shall render the agreement null and void.

3. I agree to abide by and undertake to familiarise myself with the rules of the scheme as amended from time to time and grant my employer the right to deduct from my remuneration any amounts (including members portions) outstanding by myself to CompCare Medical Scheme. I further grant my employer the right to pay such monies over the scheme.

4. I confirm that I have received a copy of the current Member Benefit Guide and understand the contents therein.

5. I (the member) acknowledge that it is my sole responsibility as a member to ensure that the monthly premium is received by the scheme. Furthermore, I understand that I will be liable for any legal costs incurred in the recovery of any amount owing to the Scheme on the attorney and own client scale.

6. I agree that contribution late joiner penalties may apply to my adult dependants 35 years and older if they have not been a member or a dependant of any previous medical scheme(s) or existing dependant at time of registration.

7. I understand that the scheme will not be liable for reimbursement in respect of health services obtained for any pre-existing conditions, unless the details are fully disclosed, which may be subject to waiting periods and condition specific exclusions in accordance with the Medical Schemes Act (No. 131 of 1998).

8. I agree to notify the scheme within 30 days in the event that any alternation in the circumstances on which the assessment of their risk is based, occurs between the date of this application and the date of their acceptance of the risk.

9. I declare that neither the applicant nor any of his / her dependant / s are beneficiaries of another registered medical scheme, on the date of registration with CompCare Medical Scheme.

10. I hereby acknowledge that I must give 3 (three) months written notice when I voluntarily resign from the Medical Scheme.

11. I hereby give the scheme permission to communicate to me by SMS or Email.

12. I declare that I have disclosed all particulars relevant to this application and that I am aware that any false statement or non-disclosure of information will relieve the scheme from liability and subject my membership to cancellation. I warrant that I am authorised to sign on behalf of my dependant/s. If I am illiterate, I confirm that the content of this application form and the implications thereof have been read and explained to me.

13. I also authorise any doctor or other person, who may be in possession of or hereafter acquire information about my health or the health of my dependants, to disclose the information to the Scheme and its contracted third parties, provided such information shall be treated as confidential at all times. I confirm that I have the required consent of my dependants to share information of such dependants with the Scheme and its contracted third parties.

14. I understand that my confidential health and personal information will only be used for the purposes as outlined by the Scheme on the application form and any deviation from this constitutes a breach of confidentiality.

15. In the event that the Scheme wishes to use my (or my dependants’) confidential information for purposes other than those outlined in the application form, the rules of the Scheme and the MSA, the Scheme is required to obtain further consent from me (or my dependants).

16. I agree to inform the Scheme of any changes in my or my dependants’ personal status, as required by the Scheme rules, within 30 days of the change in circumstances.

17. I shall ensure that the Scheme is at all times in possession of accurate and up-to-date information about my dependants and I as it may impact on the assessment of my application for membership, the administration of my membership, payment of claims and communication by the Scheme with me.

18. I acknowledge that my dependants and I may have access to our personal information held by the Scheme and request the Scheme to correct any inaccurate information as prescribed by applicable legislation.

19. I further acknowledge that the personal information of my dependants and I shall be retained as part of the records of the Scheme for as long as it is required by the Scheme for lawful purposes, as may be required by applicable legislation and for historical, statistical or research purposes subject to the requirements of applicable law.

20. If any of my dependants or I have any concern about the processing of our personal information, we can raise the matter with the Scheme by contacting the Principal Officer.

21. I consent to all conversations between myself and the Scheme or its contracted third parties being recorded.

22. II confirm that I am familiar with the terms of this agreement, being the conditions, limits and benefits of the Scheme.

23. I hereby guarantee that as the main member of the Scheme, to the extent that it may be required by law, that I have received the necessary consent from my dependants to access and view their healthcare claims made on my membership and deal with all matters relating to their claims on my membership as set out in this section.

24. I acknowledge and appoint the financial advisor contracted by my employer from time to time (where applicable) for matters relating to my membership.

25. I understand that I will be liable for any legal costs incurred in the recovery of any amount owing to the Scheme on the attorney at own client scale.

26. I confirm that I am aware that my contributions will change according to my monthly income including commissions and other earnings should I join the NETWORX or NETWORX ED options.

27. I accept that penalties may be applied in terms of the Medical Schemes Act. I understand that these penalties include a 3 month general waiting period, a 12 month waiting period on pre-existing conditions and, where applicable, a late joiner penalty fee.

28. I confirm that I have received a current copy of the benefits and understand the contents therein.

29. I confirm that once I am enrolled as a member who has not joined as part of an employer group, that I may terminate membership to the Scheme by giving 3 months written notice in terms of the Scheme Rules.

I confirm that I have read and understood the above acknowledgements and declarations. I have had the opportunity to question and consider these and I agree to them. My signature below confirms that I voluntarily give consent to the above on behalf of myself and my dependants.