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(Note: All information will be kept strictly confidential)


SELECT YOUR REQUIREMENT *




MEMBER INFORMATION

NUMBER OF ADULT DEPENDANTS 21 YEARS & OLDER (including spouse):

AGES OF ADULT DEPENDANTS 21 YEARS & OLDER (including spouse):

NUMBER OF CHILD DEPENDANTS UNDER 21 YEARS:

AGES OF CHILD DEPENDANTS UNDER 21 YEARS:


MONTHLY INCOME
(Only applicable should you earn less than R15 000.00 per month for Network / Capitation options)

CHRONIC CONDITIONS

REQUIREMENT SPECIFICS

DO YOU REQUIRE ONLY IN-HOSPITAL COVER OR IN AND OUT OF HOSPITAL:


DO YOU REQUIRE A WELLNESS PRODUCT SUCH AS VITALITY OR MULTIPLY:


Have you or any of your dependants:




Required documentation

The following documents will be needed with our appointment:

* = Mandatory ** = If applicable

  1. Copy of ID document of Principal member and ALL dependants *
  2. Membership certificates of ALL previous medical schemes *
  3. Proof of bank account (Bank statement / cancelled cheque / Letter from bank) *
  4. Any supportive medical reports for chronic conditions **
  5. Student registration if dependant is a student and older than 20 years **
  6. Proof of monthly income, should an option with income bands be chosen, in the form of: **
    1. Your last three bank statements AS WELL AS
    2. Your last three months’ pay slips OR most recent IRP5 certificate OR
    3. If you are self-employed, your most recent audited income statement OR
    4. If you are a pensioner, proof of annuity and/or employer pension and/or State Older Person’s Grant OR
    5. If you are unemployed, UIF certificate OR
    6. If you are a student, formal proof of enrolment at an academic institution (student cards aren’t acceptable proof).

Disclosure

  1. Manage All is accredited with the Council for Medical Schemes (ORG 113) and an authorised financial service provider, licensed at the Financial Sector Conduct Authority (FSCA) (FSP 14445);
  2. Manage All represents and markets various Medical Schemes and related Health Insurance products;
  3. Manage All receives 3% or maximum R94.77 plus VAT, whichever is the lesser, commission of the Medical Scheme’s product contribution from Medical Schemes;
  4. Manage All’s monthly professional fee is 2.9% plus VAT – maximum R85.00 plus VAT, in accordance with the Medical Schemes Act, Act 131 of 1998, Reg. 28(6)(b) for all other services to the client;
  5. Should you accept our quote, we need to meet to complete all the application forms and to explain the chosen products.