App form BonCap.indd - Affordable Medical Cover

BonCap income declaration form
This form is only to be used by members who have selected the BonCap Option.
Instructions
•
•
•
•
•
Complete this application form in black ink
Print clearly using capital letters
Mark with an X where necessary
Please attach the documents required to this form
This form must be completed after reading through the Bonitas Product Brochure.
Please note: We cannot process your application if it is incomplete, incorrect or you have not attached the correct documents to it. Members on BonCap may
only be treated by a doctor or hospital on the BonCap Network.
Section 1: Main member’s details
Please fill in your details below. Ensure that all fields are marked clearly and can be read easily.
Title:
Surname:
First names:
Identity number:
Date of birth:
Tax number:
Marital status:
Gender:
Ethnic group:
Black
M
Coloured
Cellphone:
F
Indian
White
Asian
Telephone (h):
Telephone (w)
Email:
Please select the income-band that applies to your gross monthly income:
Under R6100
R6101-R9950
R9951-R13590
More than R13591
Please note: If you do not send through proof of income you will be defaulted to the highest income band. Members on BonCap may only be treated by a
BonCap network doctor and hospital.
Section 2: Spouse/partner’s details
Please fill in your spouse/partner’s details below. Ensure that all fields are marked clearly and can be read easily.
Title:
Surname:
First names:
Identity number:
Date of birth:
/
/
Tax number:
Marital status:
Gender:
Ethnic group:
Black
Coloured
Cellphone:
M
Indian
F
White
Asian
Telephone (h):
Telephone (w)
Email:
Please select the income-band that applies to your spouse’s gross monthly income.
Under R6100
R6101-R9950
R9951-R13590
P.O. Box 1101, Florida Glen 1708
More than R13591
Administered by Medscheme Holdings (Proprietary) Limited l Version: OCT 2014
Call Centre 0860 002 108 Fax (011) 758 7171 Email [email protected]
1
Section 3: Contribution payer’s details
This section must only be completed for members whose premiums will be paid by a third party, for example if your premiums are paid by your parents or
children. The third party must fill in their information below and sign the declaration.
Title:
Surname:
First names:
Identity number:
Date of birth:
/
/
Tax number:
Relationship to main member:
Ethnic group:
Gender:
Black
Coloured
Cellphone:
M
F
Indian
White
Asian
Telephone (h):
Telephone (w)
Email:
Bank name:
Branch code:
Branch name:
Name of accountholder:
Account number:
Account type:
I instruct Bonitas to electronically collect contributions by debit order, using the information above. I understand that transfers cannot be done to and from
credit card accounts. I also irrevocably authorise Bonitas to adjust any incorrect transactions and/or correct any electronic transfer or funds errors without
prior notice.
Contribution payer’s signature:
Section 4: Declaration of income
BonCap contributions are income-based. We will look at the higher gross monthly income of you or your spouse/partner to determine your contribution.
Please fill in your information below.
Description of income
Main member
Spouse/partner
R per month
R per month
Salary or wages
Commission and other rewards
Pensions or annuities
Rental income
Trust distributions
Government grants
UIF payments
Interest on investments
Subsidy of any kind
Maintenance
Other income
Total income
R
R
We also require the documents in the table below to be attached to this form for you and your spouse. If the required documents are not submitted with
the application form and declaration of income form, you will be defaulted to the highest income-band.
P.O. Box 1101, Florida Glen 1708
Administered by Medscheme Holdings (Proprietary) Limited l Version: OCT 2014
Call Centre 0860 002 108 Fax (011) 758 7171 Email [email protected]
2
If you
We need
Earn a monthly salary
Your latest payslip
or
Letter from employer/company that confirms your income
or
Your latest IRP5
and
Your bank statements for the last 3 months (showing your monthly income and other consistent
additional incomes, if applicable)
Are paid weekly wages
Your last 4 payslips
or
Letter from employer/company that confirms your income
or
Your latest IRP5
and
Your bank statements for the last 3 months (showing your monthly income and other consistent
additional incomes, if applicable)
Earn commission
Your payslips or commission statements for the last 3 months
or
Your latest IRP5 (not older than 6 months)
and
Your bank statements for the last 3 months
Are self-employed
A copy of your IT34
or
Letter from an external auditor or accounting firm confirming your income
and
Your bank statements for the last 3 months
Are a pensioner
Most recent pension statement
or
Pension income letter (not older than 6 months)
and
Last 3 months personal bank statements
and
A copy of your IT34
If you are a full-time student
or
unemployed
UIF statement
or
Retrenchment letter
or
Proof of registration from your tertiary institution
and
Your bank statements for the last 3 months
Foreign national
A copy of your passport
and
A copy of work permit
and
A copy of your work contract reflecting your contract period
and monthly income
and
Your bank statements for the last 3 months
Are permanently disabled
Disability grant letter
or
A doctor’s letter stating disability
or
A copy of your IT34
and
Your bank statements for the last 3 months
Please note: Bank statements submitted must clearly show the money earned being deposited into the account.
Section 5: Acknowledgement and consent
By signing this form, you declare that the information given is true and correct and that you give Bonitas Medical Fund permission to verify the declared income
of you and your spouse/partner. Declaring income lower than your actual income is fraud. This will lead to the immediate cancellation of your membership and
you will not be able to join Bonitas Medical Fund again.
Main member’s signature:
Date:
Spouse/partner’s signature:
Date:
P.O. Box 1101, Florida Glen 1708
Administered by Medscheme Holdings (Proprietary) Limited l Version: OCT 2014
Call Centre 0860 002 108 Fax (011) 758 7171 Email [email protected]
3