Membership Application Form

Medical Scheme Membership Application Form

Name of Medical Aid Fund:

Principal Officer (First Name(s) & Surname):

Physical Address of Medical Aid:

Postal Address of Medical Aid:

Email address:

Telephone:

Fax:

Company Registration Number:

NEW MEMBERS

Number of “principal” members as at 31 December of the previous year:

Trustees[1]

Trustees[2]

Trustees[3]

Trustees[4]

Trustees[5]

Trustees[6]

Trustees[7]

Trustees[8]

Trustees[9]

Trustees[10]

ADMINISTRATOR

Physical address of Administrator:

Postal address of Administrator:

Telephone:

Fax:

FUND MANAGER

Physical address of FundManager:

Postal address of FundManager:

Telephone:

Fax:

TERMS & CONDITIONS

Please note that BHF members are bound by the BHF Articles of Association.

The fee is payable in advance on an annual basis as per board approved rates in January of each year.

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Please attach the following documents with the application form:

Complete Member Application Form

Copy of the scheme’s latest audited financial statement:

Copy of the scheme’s registration documents: