BOTLHE MEDICAL AID SCHEME - APPLICATION FORM
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1 What you must do Once you have submitted your application form, here is what will happen: - If any details are missing or if we need more information for underwriting purposes, we will contact you. - We will send you a letter of confirmation if you qualify according to the terms and conditions of the scheme prior to activating your membership. Your membership will be activated after the 3 months waiting period. - BOTLHE MEDICAL AID SCHEME - APPLICATION FORM Thank you for deciding to apply to join the BOTLHE MEDICAL AID SCHEME. This document is an application form for membership, please complete all the questions relating to your medical history and make sure you read and understand the scheme rules. Who we are Botlhe Medical Aid Scheme (referred to as the Scheme or BMAS ), is the medical aid scheme that you are applying to become a member of. Unigem (Pty) Ltd (referred to as the Administrator ) takes care of the administration of your membership for the Scheme. Fill in the form in black ink, please print clearly. Read and understand the rules for membership. Sign the form Sign and date any changes. Fax the completed and signed form to or it to info@unigem.co.bw Please attach a copy of each applicant s identity document and valid passports or birth certificates for children. Upon activation, we will SMS or you to let you know that your membership has been activated and depending on your instructions, we will either send you your welcome pack or you can collect it form the office where you submitted your application. If you do not hear from us seven days after submitting your application form, please contact us on or When you sign this application, you confirm that you have read and understood the rules for membership and agree to them. 1
2 APPLICATION FORM PRINCIPAL MEMBER DETAILS First Name Omang Surname Membership Number Gender Postal Address Address of Birth Marital Status Single Married Divorced Widowed Mobile Employer Tel. (W) Tel. (H) Bank Branch Code Branch Name Account Number Debit Card Number Expiry Benefit Option Executive Cover Classic Cover Basic Cover Embedded Cover P66.50 Embedded Cover P48.00 Embedded Cover P31.50 Are you a member or dependent of any another medical aid scheme? Nature of membership NO YES Preferred Doctor Name of Scheme DEPENDENTS MEMBERS TO BE COVERED First Name Surname of birth Relationship Omang Embedded PREMIUM CALCULATIONS Description Number Amount per additional dependent TOTAL Principal Member 1 Dependents with Embedded Cover TOTAL PREMIUM PAYMENT DETAILS Direct Debit PAYERS BANK DETAILS Cash/Cheque etc. To be paid by Self Other* *Complete payers details below if other Account Name Bank Branch Code Branch Name Account Number Due Amount Effective Relationship with Principal Member Account Holders Signature ASSISTED BY: FULL NAMES Signed for and on behalf of Botlhe Medical Aid Scheme 2
3 MEDICAL HISTORY Have you or any dependant in this application ever experienced, been treated for, or are you currently suffering from any of the following symptoms, conditions or disorders? We have listed some examples of conditions, symptoms or disorders under each question. These are only examples and not the full list of conditions, symptoms or disorders. Please include congenital abnormalities. Please take note that if you have any symptom or condition not listed in the questions below, you should highlight and provide full details of this symptom or condition in response to question 18 below. 1 Tumours and growths Example: abnormal pap smear results, pre-cancerous skin lesions, breast disease, breast lumps, non-cancerous tumors, cancerous tumors, fibrocystic breast disease, fibroadenoma, fibroadenosis, lump in breast, abnormal mammogram result, abnormal PSA (prostate specific antigen) result 2 Heart and circulation conditions Example: chest pain, palpitations, shortness of breath, coronary heart disease, angina, heart attack, arrhythmia, high blood pressure (hypertension), cardiomyopathy, valvular heart disease or heart valve replacement, congenital heart disease, rheumatic fever, high cholesterol, previous heart surgery, stents, pacemaker 3 Gynaecological and obstetrics conditions Example: abnormal pap smear results, abnormal menstrual bleeding, endometriosis, miscarriage, polycystic ovarian syndrome, infertility. 4 Mental health Example: mood disorders (depression, bipolar disorder), anxiety disorders, schizophrenia, personality disorders, sleeping disorders (like narcolepsy), eating disorders, Alzheimer s disease, autism, dementia, attention deficit-hyperactivity disorder, drug and/or alcohol rehabilitation, suicide attempt, counselling, bulimia and any other psychological conditions. 5 Metabolic or endocrine conditions Example: diabetes (high blood sugar), thyroid disease, Addison s disease, Cushing s syndrome, metabolic syndrome, parathyroid disease,paget s disease, osteoporosis, growth deficiency, metabolic disorders, Conn s syndrome 6 Abdominal conditions Example: hepatitis, cirrhosis, portal hypertension, alcoholic liver disease, liver failure, haemochromatosis, pancreatitis, cystic fibrosis, gall bladder, gall stones, GORD (heartburn), oesophageal disease, hernias, atrophic gastritis, ulcers, malabsorption, Crohn s disease, ulcerative colitis, diverticulitis. 3
4 7 Brain and nerve conditions Example: stroke, epilepsy, multiple sclerosis, motor neuron disease, myasthenia gravis, migraine, cerebral palsy, Parkinson s disease, paraplegia, hemiplegia, quadriplegia, spinal cord injury, hydrocephalus, mental retardation and CVA. 8 Breathing and respiratory condition Example: asthma, chronic obstructive pulmonary disease, bronchiectasis, tuberculosis, bronchitis or emphysema, cystic fibrosis, sarcoidosis, pneumonia 9 Musculoskeletal (back, bone and muscle pain) Example: arthritis (any form), ongoing back pain, ankylosing spondylitis, lupus, Sjögren s syndrome, scleroderma, polymyositis, dermatomyositis, polyarteritis nodosa, Wegener s granulomatosis, sarcoidosis, fibromyalgia, degenerative disc disease, scoliosis, kyphosis, spinal stenosis, gout, fractures, physical disability. 10 Kidney or urinary conditions including current or past dialysis Example: kidney and/or renal failure, kidney stones, recurrent urinary infections, glomerulonephritis, nephrotic syndrome, polycystic kidney disease, urinary incontinence, bladder infections, other bladder or kidney problems. 11 Blood conditions Example: deep vein thrombosis, anaemia, ITP (platelet deficiency), polycythaemia vera, blood clotting diseases, leukaemia, lymphoma, pulmonary embolus, haemophilia and other bleeding disorders. 12 Eye conditions Example: cataract, keratoconus, corneal ulcer, uveitis, glaucoma, squint, ptosis, any abnormality of eyelids, retinopathy macular degeneration, cornea transplant, eye surgery, blurry vision, blindness (partial or full), retinal detachment 13 Ear, nose and throat (ENT) and dentistry conditions Example: chronic otitis media (middle ear infection), chronic otitis externa, hearing problems, hearing aid, cochlear implant, tonsillitis, adenoiditis, vertigo, deafness, sinus problem, nasal surgery, dental treatment or dental surgery. 4
5 14 Male urogenital conditions Example: prostate disorders, urogenital defects, varicocele, tumours, undescended testes, phymosis, urinary incontinence 15 Are you or any of your dependants expecting surgery or planning hospitalisation or treatment in the next 12 months or have you been admitted to hospital in the last 12 months? 16 Have you or any of your dependants received medical advice or treatment for symptoms, not yet diagnosed by a medical professional, in the last 12 months before this application? 17 Have you or any of your dependants received medical advice or treatment for symptoms, not yet diagnosed 18 Have you or any of your dependants been diagnosed with or received treatment for, any condition not mentioned in the questions above, in the last 12 months before this application? PRE-EXISTING CONDITION EXCLUSION Any injury, illness or physical defect that arose prior to the commencement of this policy that you suffered from, were aware of, or received medical treatment or advice for (the pre-existing conditions) is specifically excluded. SIGNATURE OF PRINCIPAL MEMBER 5
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