HEALTH SERVICE BENEFITS – Individual Analysis

NAME : …...…………………..………………………………………………………………………………………….

ADDRESS : …………………………………..………………………………………………………………………….

Dependents : Name : 1..………………………………………… 2.……………………..…………………………

Age : 1…………………………………………. 2………………………………………………...

Relationship : 1…………………………………. 2………………….………………………….....

NB: If over 18 please state why still a dependent: ……………………………………………………………….

……………………………………………………………………………………………………………………………...

NB: If not living with proposer please state why still a dependent: ………………………………………….

………………………………………………………………………………………………………………………………

Yes / No

Have you enjoyed previous medical scheme coverage? ………………………………….

On what option? …………………………………………………………………………………………….…………..

How long were you a member? ………..……………………………………………………………………………..

Current medical aid: ……………………………………………………………………………………………………

On what option? ………………………………………………………………………………………………………..

Yes / No

Does this include a savings account? ………………………………………………………..

If so, to what amount? R…………………………… How long on this scheme? …………………………...

Yes / No

Does your current employer contribute to any medical aid cost? ……………………..

If so, to what extent? R……………………………..

What have you spent in the past 12 months for :

1.  Medical aid premiums? …………………………………………………………. R………………..….

2.  Costs procedures not covered by medical aid? …………………………… R….………………..

3.  Any costs in excess of the medical aids limits? …………………………… R…………………...

Yes / No

Is this typical for the last 3 years? ……………………………………………………...

Yes / No

Do any of the proposed dependents suffer from a chronic condition? …………

If so, please provide full details of the condition, the required medication and currently monthly

expenditure for such medication …………………………………………………………………………………...

……………………………………………………………………………………………………………………………....

………………………………………………………………………………………………………………………………

Yes / No

Do any of the members suffer from any disability? …………………………………

Page 2

If so, please provide full details of this and any required medication? …………………………......

………………………………………………………………………………………………………………………………

Are there any major expenses will need to be covered in the next 12 months e.g. dentistry, eye wear,

Yes / No

prescribed medication? ……………………………………………………………………

If so, please provide details. …………………………………………………………………………………………

………………………………………………………………………………………………………………………………

Were the following explained :

Medical savings account / clawbacks
Vitality
Consequences of client providing inaccurate information:
Cost issues
Waiting periods / penalties/exclusions

Plan Selection :

Quotation :

Risk Contribution : ......

Day to Day

MSA : ………………………………….

ARB : ………………………………….

Vitality : ………………………………….

KeyClub : ………………………………….

HPP : ………………………………….

Total premium : ………………………………….