NEW MEMBER APPLICATION FORM

PULA MEDICAL AID FUND Administered by Associated Fund Administrators Botswana ( Pty) Ltd.
Gaborone: AFA House • Plot 61918 • P O Box 1212 • Gaborone • Botswana • Telephone: (+267) 365 0555 (Call center) / 365 0500 (Reception) • Fax: (+267) 395 1165
Francistown Branch: Plot 32397 • Office 26 Sunshine Plaza Francistown • P O Box 323 Francistown Botswana • Telephone : (+267) 241 2290 / 2390
www.pulamed.co.bw

*please choose your option

INDIVIDUAL MEMBER CORPORATE MEMBER
Joining under company

Choose Option: EXECUTIVE DELUXE GALAXY STANDARD FLEXI

P2 Million Cover P1.2 Million Cover P100,000 Cover P40,000 Cover P60,000 Cover

About yourself (principal member)

Marital Status: Married Single Divorced Widowed

Title Initials Surname

First name(s) Sex M F Date of birth

Occupation Relation to PIP Yes No , if yes, please state relationship

ID or passport number Country of Issue Country of Origin

*Attach certified copy of valid Identification document (Omang for citizens and Passport for foreign nationals

Basic Salary P Employee Number

*Attach copy of recent payslip/bank statement (not older than 2 months)

Source of Funds utilised to pay contribution

Cell Tel (H) Tel (W) Fax

Email

Postal Village/Town Physical

Address Address
Proof of address *Attach Utility Bill, Lease agreement, Title Deed, Letter from Kgosi, Affidavit

About your spouse (only complete if adding spouse)

Title Initials Surname

First name(s) Sex M F Date of birth

Employer

ID or passport number Country of issue

Cell Tel (H) Tel (W)

Email
*Attach copies of marriage certificate and spouse ID

About your dependants (*only complete if adding child dependants)

FAMILY MEMBERS TO BE COVERED

First Names & Surname(s)

Birth Dates Gender Passport Number

M F
M F
M F
M F
M F

Date of commencement of employment IMPORTANT

Date of joining the Fund Failure to complete all information and
attached document required will delay
Name of previous Medical Schemes processing of membership. Failure to
disclose material information or provision
Date of previous membership From: To: of incorrect information can result in the
immediate cancellation of membership.
Membership Number
* 072020PULA
Your employment details ( please complete if joining under company)

Name of Employer

Industry Date of employment

Employer warranty ( please complete if joining under company)

We warrant that the main applicant detailed in the first section of this application form is an employee of our organisation.
Pula Medical Aid Fund may bill us for the amount due for this member in the same way as it does for our other employees with Pula Medical Aid Fund

Name

Designation
EMPLOYER’S STAMP
Email

Telephone

Postal Address

Authorised signatory:________________________________________________________

Your banking details

Please note: we can not accept credit card account details

Bank name

Branch name Branch code

Account number Type of account Cheque Savings

Account holder

By signing this application, you agree that claims will be refunded into the account you have chosen.

Signature of the Principal Member:________________________________________________________

*please attach a clear copy of your recent payslip (not older than two months)
*please attach proof of account (cancelled cheque/bank statement)

Nomination for funeral benefit payout

In the event that the principal member passes on, the person named below will be legible to claim for the funeral benefit payout.

Surname

Name

ID number

Contacts

Address

Relation
* please complete the Medical History and General Health infomation form
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MEDICAL HISTORY AND GENERAL HEALTH INFORMATION
PULA MEDICAL AID FUND Administered by Associated Fund Administrators Botswana ( Pty) Ltd.
Gaborone: AFA House • Plot 61918 • P O Box 1212 • Gaborone • Botswana • Telephone: (+267) 365 0555 (Call center) / 365 0500 (Reception) • Fax: (+267) 395 1165
Francistown Branch: Plot 32397 • Office 26 Sunshine Plaza Francistown • P O Box 323 Francistown Botswana • Telephone : (+267) 241 2290 / 2390
www.pulamed.co.bw

First Name Surname ID/Passport No:

OPTIONAL DISCLOSURE
Although you are not obliged to disclose the Chronic/HIV AIDS status of yourself or your dependant(s) on this form, you are required, in line with the Fund
rules and underwriting criteria, to submit this form within 2 working days from the date you submit your membership application to clientservices@afa.

(please supply the required information by marking the relevant box with an X)
Yes No

1. Do you or any of your dependants use chronic medicine Yes No

2. Disorders or problems with heart or cadiovascular system, e.g heart murmur, high blood pressure, high cholestrol, Yes No
shortness of breath, palpitations, chest pains, angina, heart attack and/or other cardiac or blood disoders
3. Respiratory or lung disorders, e.g tuberculosis, asthma, persistent cough or other breathing problems, emphysema, Yes No

4. Disorders in the digestive system, stomach, gall bladder, pancrease or liver, e.g gastric or duodenal ulcers, heartburn,
hiatus hernia, rectal bleeding, Crohn’s disease, ulcerative colitis, irritable bowel syndrome, hepatitis, cirrhosis, liver Yes No
failure or have you ever had a gastroscopy or colonoscopy?
5. Diseases or disorders of the kidneys, bladder or reproductive organs, e.g abnomal urine tests, kidney stones, nephritis, Yes No
prostatitis, bladder infections or sexually transmitted diseases.
6. Disorder of the nervous system or brain, e.g epilepsy, stroke, multiple sclerosis, migraine,headaches, paralysis, Yes No
Parkinson’s disease, or have you or any of your dependants been advised to have an MRI or CT scan?
7. Yes No
disorder (ADHD), or post -traumatic stress disorder
8. Ear, nose throat or eye disorders, eg defective vision, cataracts, glaucoma, retinitis, disorders of the cornea, hearing Yes No
loss, ear discharge, otitis media or allergies
9.
any back,neck,hip,knee or other joint trouble, multiple sclerosis, any joint problems, or replacements, acne, eczema Yes No
or psoriasis?
10. Diabetes, sugar in urine, thyroid or other glandular or blood disorders, e.g anaemia bleeding disorders, growth disorder, Yes No
cushing’s disease or Addison’s disease
11. Cancer, a growth or tumor of any kind including moles removed (malignant/benign) Yes No

12. Are you or any of your dependants currently undergoing or anticipating any specialised dental, maxillofacial treatment? Yes No

13. Have you or any of your dependant had any accidents (including motor vehicle accidents)? Yes No

14. Are you or any of your dependants taking ongoing medicine for any condition no listed in any other question? Yes No

15. Have you or any of your dependants had any surgical procedure? Yes No

16. Are you or any of your dependants awaiting or planning any operation or admission to any hospital in the next 12 Yes No
months
17. Is there any other condition or symptom, which is not detailed in any other question, for which medical advice, Yes No
diagnosis, care or treatment has already been recommended or received, or could potentially result in a medical claim
within the next 12 months?
18. Yes No
disorders of the cervix, menstrual disorders or any abnormalities of pregnancy
19. Are you or any of your dependants pregnant? If so, what is the expected date of delivery? Yes No
Date: ______________________________________________________________________

Disclaimer
Please note that the following exclusions and waiting periods may be applicable as prescribed by the Fund rules, pre-existing conditions; 2 years, limited
dentistry; 12 months, 9 months maternity; and 3 months waiting period for an infant child registered after 30 days of birth or adoption.

072020PULA
If your answer was yes to any of the above questions, please provide full particulars in the space below. Please use a separate sheet of paper if the space
provided is not enough. Please also note that members with chronic conditions have to register with the Managed Care Department.

Name of the person

suffering from the illness

Question number

Illness or condition

Date on which illness

began

Date of last occurance

Name of treating Doctor

Doctor’s contact details

Treatment recommended
(medicine, etc.)

Treatment from (date)

Treatment until
(date)

Declaration

Failure to disclose material information is fraud. The provision of false, incorrect or incomplete information can result in the immediate cancellation of your membership.

I the undersigned, hereby make application to the Administrator to be admitted as a member of the Fund, and if admitted I agree to abide by the Rules
of the Fund. I declare that any false statement in the above questionnaire or the non - disclosure of any material information will render my membership
null and void. I warrant that the above answers are true, correct and complete in every respect. I hereby authorise my employer to deduct from my salary
each month the specified contribution and indebtedness to the Fund and pay the Fund on my behalf. I confirm that I am employed by the Employer in a
full time capacity. I undertake to Advise the Administrator of any change in my state of health or that of my dependents which occurs prior to my receiving
written acceptance of this application.

Signature of Member:___________________________________________ Date:_____________________________________________

T&Cs, E&OE Apply. These may change from time to time without notification. Where there is disputes, the prevailing Fund Rules will apply. PULA cannot be held liable for the information contained in this document.

072020PULA