SAMWUMED Membership Application Form

Welcome to the SAMWUMED Family!
We are so excited that you are considering SAMWUMED as your medical aid.

We can't wait to be your trusted partner in health. If at any point during the completion of this form, you require assistance, please reach out to us by calling our member call center at 0860 104 117. One of our friendly agents will be ready to assist you.

You can also ask Sammy our friendly Chatbot, any question you may have about SAMWUMED. simply click on the Sammy Icon above to chat to Sammy.

Submission Date
BEFORE WE TAKE OFF

In order to complete the application form, you will require the following information for the main member and any additional dependants. This will be required at the end of the form. Dont worry if you do not have electronic copies available, we allow you to capture the hardcopies with your webcam or phone camera. You can click on "Save" at the bottom of the page at any time if you want to return to the form later. You will receive an email with the link to your saved form.
Who is completing this form?*
You will or may require the following documents or information to complete the form:
- The email address of your municipal payroll office.
- Main member's and Dependant(s) ID Copies.
- Birth Certificate(s) (newborns - if applicable).
- Your latest Payslip.
- Membership Certificate(s) from previous medical scheme (if applicable).
- Adoption papers if a child is adopted / forstered (if applicable).
- Proof of studentship (For children between the ages of twenty-one (21) and twenty-five (25) years, if they are unmarried, attending a registered educational institution).
- A Marriage Certificate or divorce decree (if applicable).
- Affidavit for child dependant over 21 if not student (if applicable).
- An affidavit confirming residency, employment, income and marital status of dependant child and both their parents, for sibling, grandchild, nephew or niece under the age of 18 (only for special dependants).

APPLICATION FOR MEMBERSHIP

PM001
A. MAIN MEMBER DETAILS

Please enter the details of the main member here.

Identity Information
Full Name*

First NameLast Name
ID Type*
Identity Number *
Please enter your 13 digit ID number here.
Passport Number *
Please enter your 8 digit Passport number here.

Personal Information
Title*
Please select your title from the list above
Gender*
Date of Birth*

DayMonthYear
Ethnic Group*
Please select the racial group you belong to above.
Marital Status*
Please select your current marital status
Language*
Please select your preferred language.
SARS Tax Number*
Please enter your SARS Tax number in the field above.

Employment Information
Employment Status*

Active EmploymentPensioner
Method of Payment*
How will you pay your contributions?
Thank you for confirming that you will be responsible for payment of the contribution. You will be directed to provide your banking details in the next section.
Employer*
Payroll Email*

Confirmation EmailEmail Address of your Payroll Department
Payroll Number*
Enter your Payroll number here
Additional Payroll Number
Enter additional Payroll number here
Department or Directorate*
Department where you are employed
Branch*
Branch where you are employed
Occupation*
Please enter your occupation
Staff Number
Staff or employee number
Employment Date*

DayMonthYear
Commencement date
Work Phone Number
Please enter your work phone number here.
Monthly Basic Salary*
Gross income (before deductions)

Contact Information
Phone Number
Mobile Number*
Please use this format: 2783456765
Email Address

Confirmation EmailPlease enter a valid email address in the format: example@example.com

Broker Information
Did you consult a broker or one of our SAMWUMED business consultants?*
Select your Brokerage and Broker below:*
Broker Email*
Copy from the list above.
Select your SAMWUMED Business Consultant*
Business Consultant Email*
Copy from list above
Please indicate which information you would like us to provide to your broker or business consultant:*

Personal information, regarding me and my dependants, (Updating and Confirming Personal Details)Benefits information, regarding me and my dependants (Benefits Queries and Claim Queries)Financial Information, regarding me and my dependants (Banking Details, Members Portion, Suspended Details, your chosen third party can only confirm these details, no changes can be done by a third party)Medical Information, regarding me and my dependants (Diagnosis, Treatment Plans, Prescribed Minimum Benefits Guidelines)Documents Required, regarding me and my dependants (Statements, Membership Certificates, Tax Certificates)

Address Information
Street Address*

Street Address

Street Address Line 2

CityProvince

Postal
Copy street address to postal address.

YesNo
Postal Address

Street Address

PO Box Number

CityProvince

Postal Code

B. DEPENDANT DETAILS

Please provide details of your dependants who will also require cover.
Do you wish to register dependants on the Scheme?*
Select the number of dependants you wish to register.
Dependant Details*

C. PLAN SELECTION & GP NOMINATION

Choose your preferred plan.

Plan Selection
Product*

Option AOption B
Salary Band - Option A*
Please select your current salary band from the list above. Please note that you will need to submit your salary advice at the end of the form.
Salary Band - Option B*
Please select your current salary band from the list above. Please note that you will need to submit your salary advice at the end of the form.
Join Date*

DayMonthYear
Date on which you want to join.

GP Nomination
GP Full Name

First NameLast Name
GP Phone Number
Enter the GP Phone Number Above
GP Practice Number
Enter the practice number of your GP.
Do you wish to nominate a second GP?

YesNo
Second GP Full Name

First NameLast Name
Second GP Phone Number
Enter the GP Phone Number Above
Second GP Practice Number
Enter the practice number of your GP.

D. BANKING DETAILS

We require your banking details in case we need to refund you or if you will be responsible for the monthly contributions.
Account Holder Name*
Type the name of the account holder here.
Bank & Branch Code*
Please select your Bank from the list above.
Account Number*
Type the account number here.
Account Type*
Account Type you hold.
Is this your own account?*

YesNo

E. COVER HISTORY

To be completed by the Applicant in respect of himself/herself and all nominated dependants.
Have you or any of your dependants had any previous Medical Aid Cover in the past?*
Cover Declaration*

G. SUPPORTING DOCUMENTS
To register yourself and your dependant/s, please attach copies of the following supporting documents below.

You will have a choice to either upload the documents or take a photo of the document with your device.

Main Member ID Document
Upload Main Member ID Document

Upload a File

Cancelof
Take Photo of Main Member ID Document

Dependant ID Documents
Upload Dependant's ID Documents

Upload a File

Cancelof
Take Photo of Dependant's ID Documents

Birth Certificates
Upload Birth Certificates

Upload a File

Cancelof
Take Photo of Birth Certificates

Payslip
Upload Payslip

Upload a File

Cancelof
Take Photo of Payslip

Member Certificates
Upload Membership Certificate of Previous Medical Scheme

Upload a File

Cancelof
Take Photo of Membership Certificate of Previous Medical Scheme

Proof of Disability
Upload Proof of Disability (Medical Assessment Report)

Upload a File

Cancelof
Take Photo of Proof of Disability

Affidavits
Upload Affidavits

Upload a File

Cancelof
Take Photo of Affidavits

Marriage Certificate
Upload Marriage Certificate

Upload a File

Cancelof
Take Photo of Marriage Certificate

Legal Adoption Papers
Upload Legal Adoption Papers

Upload a File

Cancelof
Take Photo of Legal Adoption papers

Tertiary Institution Registration
Upload Proof of Registration at a recognised tertiary institution

Upload a File

Cancelof
Take Photo of Proof of Registration at a recognised tertiary institution

H. Welcome Pack Delivery

Once you are onboarded, you will receive a welcome pack with important information about your membership as well your membership card. We make use of PAXI to deliver welcome packs to over 2800 destinations across the country. Please make use of the collection point locator below. Enter your street address and then type the number of the nearest PAXI collection point in the space provided below the Map:
Select your nearest PAXI Collection Point
My preferred PAXI collection Point:*
Enter PAXI collection Point Nr above

I. AGREEMENT & CONSENT
Terms and Conditions*
Marketing Consent:*

YesNo
Did you complete a paper-based form and was this form stamped by your municipal Payroll Office?*
Upload Stamped paper-based application form:*

Upload Application Form
Please scan and upload the completed and stamped paper-based application form here. Cancelof
Please verify that you are a human*

J. SIGNATURE
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Welcome to the SAMWUMED Family!

BEFORE WE TAKE OFF

APPLICATION FOR MEMBERSHIP

A. MAIN MEMBER DETAILS

B. DEPENDANT DETAILS

C. PLAN SELECTION & GP NOMINATION

D. BANKING DETAILS

E. COVER HISTORY

F. EXISTING CONDITIONS

G. SUPPORTING DOCUMENTS

H. Welcome Pack Delivery

I. AGREEMENT & CONSENT

J. SIGNATURE