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Main Applicant Details Fill in N/A if a particular field is non-applicable

Employer Details Fill in N/A if a particular field is non-applicable

Partner/Spouse Details Fill in N/A if a particular field is non-applicable

Dependant Details Fill in N/A if a particular field is non-applicable

Dependant 1

Dependant 2

Dependant 3

Dependant 4

Dependant 5


MEDICAL HISTORY QUESTIONNAIRE Fill in N/A if a particular field is non-applicable

It is most important that the questions on the following be answered as thoroughly as possible. The answers to these questions will be treated as confidential. It is important to note that any medical condition, of which you are aware, not disclosed in this application, can be excluded from benefit. Please advise whether you or any of your dependants suffer from, or have suffered from, or received treatment/consultation for any of the following conditions. Please ensure that you underline the appropriate condition, tick and complete the appropriate block/s.

  Weight and Height DetailsFill in N/A if a particular field is non-applicable
  PRACTITIONER AND/OR SPECIALIST DETAILS (you or your dependants have contacted recently)Fill in N/A if a particular field is non-applicable

Account Details

I authorise COMMED to draw from my bank account (wherever it may be), the contribution in terms of the Rules of COMMED, without prejudice to the rights of COMMED. I further authorise COMMED to increase the amounts due to it, in terms of the rules, from time to time and authorise my bank to effect payment of such increased amounts upon receipt of a written notice from COMMED stating the increased amount and the date from which it is payable. This authorisation is to remain in force until I cancel it by giving written notice to COMMED. I agree that am not entitled to recover any amount drawn from my account by means of this debit order and that, should my bank/building society repay such amount to me, I will refund it immediately to COMMED. I undertake to notify COMMED immediately of any change in respect of my address or bank/building society. I acknowledge that COMMED may not cede or assign any of their right to any third party without my prior written consent and that I may not delegate any of my obligations in terms of this contract to any third party without prior written consent of the authorised party.

COMMED is hereby authorised to debit my bank/building society account with my portion of accounts paid on my behalf by COMMED.


I hereby instruct and authorise you to pay any claim reimbursement which may accrue to me, to the credit of my account with the above mentioned bank or any other bank or branch to which I may transfer my account.

I understand the remittance advices/payment advices will be supplied to me in the normal way and that they will indicate the date on which funds will be available in my account.

I acknowledge that the party hereby authorised to effect a credit against my account may not cede or assign any of its rights to any third party without my prior written consent and that I may not delegate any of my obligations in terms of this contract/authority to any third party without written consent of the authorised party.

This authority may be cancelled by me giving you third party’s notice in writing.


Payments: Your contributions are deducted from your salary by your employer or direct from your bank account. You pay contributions monthly in advance. Increases: All medical schemes increase contributions from time to time when the cost of medical, dental, hospital and other health services are increased, and when benefits are improved. Normally increases are effected annually.

COMMED reserves the right to impose waiting periods as defined in the Rules. Should any of these apply to you, you will be notified in writing by COMMED before commencement of membership. Please supply full details on a separate sheet of paper and attach to the application if you or your dependants have had one or more pre-existing medical condition/s during the last 12 months. (Exclude minor ailments).
Any deterioration or change in my state of health or in that of any of my dependants before the date of event to be set by COMMED for the commencement of membership or the date of acceptance of this application by COMMED or the date of receipt of the first subscription, whichever date is the latest shall entitle COMMED to reconsider the application and propose new terms of admission or declare the membership null and void in which case all moneys paid to COMMED in connection with this membership before COMMED is informed of the change, shall be forfeited and benefits paid by COMMED shall immediately be refunded to COMMED.

Resignation: (You may only resign subject to the conditions laid down in the Rules of COMMED as amended from time to time).
Membership card: The membership card is for use by the principal member and/or his dependants only. Registration: You must register all your dependants with COMMED, unless they belong to another medical scheme. You must also notify COMMED within 30 days of any change in marital status and or dependant and or salary status that occurred since you joined COMMED.
Termination of voluntary or individual membership may require 2 months written notice and 3 months notice from companies by the scheme.

I hereby make application for membership of COMMED and agree that I will be bound by the Rules of COMMED as amended from time to time.
I declare that the answers to the above questions are, to the best of my acknowledge and belief true in every respect and I agree, in the event that any of these answers are knowingly inaccurate, to forfeit all benefits from COMMED, to refund in full, grants that may have been paid on my behalf by COMMED, and to waive all claims to any subscriptions paid by me to COMMED.
My employer is hereby authorised to debit my salary with my portion of the monthly contribution required. My employer is authorised to continue thereafter to pay each month such amounts as are due until the end of the month in which COMMED is notified of my resignation.
I agree that, should any sum due to COMMED not be timeously paid by me for any reason, I shall be liable for all costs incurred by COMMED in the recovery of such a claim, including tracing charges and all fees and costs charged to COMMED by its attorneys, including collection commission.
Penalties and waiting periods may apply to late joiners. I accept that I and/or my dependants may be subjected to a general waiting period of 3 months. For any pre-exsisting condition/s within the last 12 months, a waiting period of 12 months may be applied. I acknowledge that in terms of S57(4)(i) of the Medical Scheme Act, the Board of Trustees must take all reasonable steps to protect the confidentiality of medical records concerning my state of health and in respecting the privacy of my dependants will exercise similar controls with regard to their health records. Subject to those obligations, I hereby consent to and authorise the disclosure of any such information, both to the Scheme and any other person by the provider concerned or by the Scheme itself if, in the opinion of the Scheme, there is good reason to do so.


BROKER DECLARATION Fill in N/A if a particular field is non-applicable


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