Admed Claim Form Guardrisk Insurance Company Limited PO Box 786015 SANDTON 2146 Tel: 0860 102 936 Fax: (011) 263-1419 Email: admed@guardrisk.co.za

Admed Products: AdmedGap AdmedPulse

A: NAME OF EMPLOYER :

DIVISION :

B. MEMBER’S PARTICULARS:

Full Name of Member: I.D. Number of Member: Date of Birth:

Tel : (Work)

Tel: (Home)

Postal address of Member: ………………………………………………………………………………………………………................. Tel : (Cell )

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Email Address: Fax :

Joining date: Employer

Joining date: Medical Aid Fund

Medical Aid Fund: Medical Aid Fund Number:

C: PATIENT’S PARTICULARS:

Relation to Member (Please tick the appropriate box):

Date of Birth: Full Name of Patient:

Self Spouse Child Other

D: REASON FOR HOSPITALISATION: (Please tick the appropriate box)

1. Illness 2. Accident 3. Childbirth

Name and address of hospital: Date of hospitalisation:

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1. Admitted: .....……….. Discharged: …........…..

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2. Admitted: ………….... Discharged: …..…….....

For office use only CLAIM NO:

E: DETAILS OF CLAIM: DATE OF SERVICE SERVICE PROVIDER AMOUNT

CHARGED PAID BY MEDICAL

AID SHORTFALL

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NB - YOUR CLAIM CANNOT BE PROCESSED WITHOUT SUPPORTING DOCUMENTATION. PLEASE ENSURE THAT YOU ATTACH COPIES OF THE RELEVANT CLAIMS

(HOSPITALS/SPECIALISTS/ANAETHETIST) AND THE CLAIMS ADVICE FROM YOUR MEDICAL AID.

F: ADMED PRINCIPAL MEMBERS BANK ACCOUNT DETAILS: Following acceptance of my claim, a. pay the benefit into my bank account

a. Name in which account is registered: __________________________________________________

b. Type of account: ___________________________________________________________________ (Current /Savings/Transmission)

c. Name of Bank / Building Society: _____________________________________________________

d. Branch Name: ____________________________________________________________________

e. Branch Code: _____________________________________________________________________

f. Account Number: __________________________________________________________________

b. mail the benefit cheque to:

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G. DECLARATION BY PRINCIPAL MEMBER:

I declare that the above particulars are true in every respect and I attach copies of all hospital and other medical accounts. I hereby authorise any hospital, physician or other person who has attended to me, or examined me or my dependants, to furnish to Guardrisk or its authorised representative any information with respect to any illness or injury, medical history consultation, prescriptions or treatment and copies of all hospital or medical records. A photocopy of this authorisation shall be considered as effective and as valid as the original.

Principal Member’s Signature: Date:

How to Claim Claims must be submitted to Guardrisk Insurance Company Limited as well as your relevant medical aid scheme. Following an admission to hospital the Insured must notify the administrators of any claim in writing but not later than six (6) months from the date of admission into hospital. Notify Guardrisk Insurance Company Limited in writing of your claim by completing a claim form. Submit the claim form to: GUARDRISK INSURANCE COMPANY LIMITED P O BOX 786015 SANDTON 2146; Fax to (011) 263-1419; or Email to admed@guardrisk.co.za as soon as possible Once you have submitted your claim form, copies of all related accounts (i.e. Hospital, Surgeon & Anaesthetist accounts and copies of your medical aid statements) must be forwarded to us Claims forms must be received by Guardrisk Insurance Company Limited within six (6) months of the first day of your hospital confinement. Claim forms are obtainable from your employer or Guardrisk Insurance Company Limited. Waiting Periods Waiting periods applicable to Voluntary membership groups:

• Birth related claims – 10 months. • First 6 months 0% benefit and 50% of the normal Admed benefit in the second 6 months for:

o Joint replacements (except as a result of an accident/injury occurring after joining), o Arthroscopy (except as a result of an accident/injury occurring after joining), o Spinal surgery including spinal fusion (except as a result of an accident/injury occurring after

joining), o Nasal surgery including sinus related (except as a result of an accident/injury occurring after

joining), o Cataract surgery, o Hysterectomy (except for cancer diagnosed after joining), o Dentistry related claims (except reconstructive as a result of an accident/injury occurring after

joining), o All hernia repairs (except as a result of an accident/injury occurring after joining), and o All cardiac related surgery and procedures (including angioplasty, cardiac catheterization etc)

diagnosed prior to date of joining. Enquiries Enquires should be addressed to one of the administrators at Guardrisk Insurance Company Limited: Tel: 0860 102 936 Fax: (011) 263-1419