Application Form - International

Important: Please read the following before completing this application form:
- It is compulsory to complete all the fields in this form.
- Please submit your completed form and documents required (see table below) to our Liberty Health Cover in-country office.
- Existing members who wish to register additional dependant(s), please complete the Liberty Health Cover Amendment Form.
- Activation of membership is dependent on the submission of all the required documentation.
PERSONAL DETAILS | PRINCIPAL MEMBER / EMPLOYEE
Last Name*
First Name(s)*
Title*
Other Names
Initials*
Date of Birth*
YYYY dash MM dash DD
Gender*
- Male
- Female
Permanent Employment Start Date*
YYYY dash MM dash DD
Commencement Date of Cover*
YYYY dash MM dash DD
Plan*
Group Name*
Sub Group Name*
Physical Address*
Postal Code*
Postal Address (if different to Physical Address)
Postal Code
Name of Employer*
Employee Code / Number*
Occupation*
Town / Village of Residence*
Please include country and area code for home, work and mobile numbers below.
Home Telephone
Work Telephone
Contact Telephone Number*

Telephone Number should be in the following format: +27211234567
Email*
BANKING DETAILS
Account Holder Name*
Account Number*
Account Type*
Other Account Type*
Bank*
Branch Name*
Branch Code*
Swift Code
NIB
IBAN
REGISTRATION OF DEPENDANTS
Do you want to register any dependants?*
- Yes
- No
Number of Dependants*
DEPENDANT 1
Please put the full name that will appear on the Liberty Health Cover membership card
Full Name*
Town / Village of Residence*
Date of Birth*
YYYY dash MM dash DD
Gender*
- Male
- Female
Relationship to Principal Member*
DEPENDANT 2
Please put the full name that will appear on the Liberty Health Cover membership card
Full Name*
Town / Village of Residence*
Date of Birth*
YYYY dash MM dash DD
Gender*
- Male
- Female
Relationship to Principal Member*
DEPENDANT 3
Please put the full name that will appear on the Liberty Health Cover membership card
Full Name*
Town / Village of Residence*
Date of Birth*
YYYY dash MM dash DD
Gender*
- Male
- Female
Relationship to Principal Member*
DEPENDANT 4
Please put the full name that will appear on the Liberty Health Cover membership card
Full Name*
Town / Village of Residence*
Date of Birth*
YYYY dash MM dash DD
Gender*
- Male
- Female
Relationship to Principal Member*
DEPENDANT 5
Please put the full name that will appear on the Liberty Health Cover membership card
Full Name*
Town / Village of Residence*
Date of Birth*
YYYY dash MM dash DD
Gender*
- Male
- Female
Relationship to Principal Member*
HEALTH STATEMENT
All sections below must be completed - failure to do so will delay processing of this application.
First Name and Last Name of Current Family Doctor*
Telephone*
How many years has he/she been your doctor?*
Postal Address*
Postal Code*
Have you or any of your nominated dependants received medical advice, care or treatment for any of the following?

Note: If you answer “Yes” to any of the questions in this section, and if the space provided to complete your answer is not sufficient to disclose the necessary information, please provide the additional information at the end of this section.

1.	HEART & CIRCULATION
	e.g. Chest pain/Angina; Heart attack; Heart failure; Heart valve defects; Rheumatic fever; High blood pressure (Hypertension); High cholesterol; Heart murmurs; Circulatory problems/disorders; Varicose veins; Deep Vein Thrombosis (DVT or any other heart or circulatory problems)

Heart & Circulation*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

2.	BREATHING & RESPIRATORY
	e.g. Asthma; Difficulty with breathing; Bronchospasm; Tuberculosis (TB); Coughing up blood; Emphysema; Pneumonia; Cystic Fibrosis; Chronic bronchitis; Shortness of breath or any other respiratory problems

Breathing & Respiratory*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

3.	BLADDER & KIDNEYS
	e.g. Blood in urine; Kidney failure; Polycystic kidneys; Kidney or bladder infections; Kidney removal (Nephrectomy); Kidney stones; Abnormal kidney or urine tests or any other bladder or kidney problems

Bladder & Kidneys*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

4.	REPRODUCTIVE ORGANS
	e.g. Endometriosis; Infertility; Ovarian Cysts; Hysterectomy; Abnormal pap smears; Cervix or breast biopsies; Fibro-adenosis of the breast; Laparoscopies; Hormone Replacement Therapy (HRT); Prostate infections or surgery; Prostate enlargement or any other reproductive problems

Reproductive Organs*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

5.	DIGESTIVE SYSTEMS
	e.g. Duodenal ulcers; Gastric ulcers; Hiatus hernia; Colon problems; Crohn's Disease; Ulcerative colitis; Gall bladder problems; Pancreas; Liver problems or any other digestive system problems

Digestive Systems*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

6.	EAR, NOSE & THROAT
	e.g. Deafness; Ear infections; Sinus problems; Nasal surgery; Throat surgery; Orthodontics; Dental surgery; Speech impairments; Harelip; Cleft palate or any other nose or throat problems

Ear, Nose & Throat*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

7.	EYES
	e.g. Blindness (partial or full); Eye surgery; Lens implants; Cataracts; Glaucoma; Retinitis Pigmentosa; Retinal detachment; Impaired vision or any other eye or eyesight problems

Eyes*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

8.	ENDOCRINE
	e.g. Diabetes ("high blood sugar"); Underactive thyroid; Overactive thyroid; Thyroid surgery; Cushing's Syndrome; Addison's Disease; Pituitary gland problems or any other endocrine or glandular problems

Endocrine*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

9.	BACK & MUSCLES
	e.g. Neck or back problems or operations; Recurrent back pain; Osteoporosis; Ankylosing spondylitis; Rheumatoid arthritis; Osteoarthritis; Paget's Disease or any other bone or skeletal disorders

Back & Muscles*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

10.	NEUROLOGICAL
	e.g. Epilepsy; Stroke (CVA); Migraine; Brain injuries; Spinal cord injuries; Paralysis; Cerebral palsy; Multiple Sclerosis; Mental retardation; Narcolepsy; Motor Neuron Disease; Parkinson's Disease; Alzheimer's Disease or any other neurological problems

Neurological*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

11.	PSYCHOLOGICAL
	e.g. Depression; Anxiety; Psychosis; Suicide attempts; Bipolar disorders; Manic depression; "Stress"; Schizophrenia; Tourette's Syndrome; Anorexia Nervosa; Received advice, counselling or treatment for alcohol or drug abuse; Attention Deficit Disorder, Bulimia or any other psychological problems

Psychological*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

12.	TUMOURS & GROWTHS
	e.g. Benign or malignant growths or lumps or tumours including but not limited to: Melanoma; Lymph gland cancer; Leukemia and breast cancer or any other tumours, growths and cancers

Tumours & Growths*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone
13. BLOOD

Blood or bleeding disorders, e.g. Haemophilia; Christmas factor deficiency; Platelet or any other blood clotting disorders
Blood*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone
14. SKIN

e.g. Eczema; Acne; Dermatomyositis; Pemphigus; Psoriasis; Scleroderma or any other skin disorders
Skin*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone

15.	SEXUALLY TRANSMITTED INFECTIONS (STIs)
	e.g. Advice, treatment or counselling for any of the following: HIV/AIDS; Syphilis; Gonorrhoea; Herpes; Genital ulcers; Pelvic Infectious Disease (PID); Genital warts; Hepatitis B or any other STI or disorder

Sexually Transmitted Infections (STIs)*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone
16. PREGNANCY
Are you or any of your dependants currently pregnant?*
- Yes
- No
If the answer to the above question is "Yes", when is the expected date of delivery?*
YYYY dash MM dash DD
Name of Patient*
17. OTHER MEDICAL CONDITIONS
Do you or any of your nominated dependants have any medical condition not mentioned in the above questions 1 to 16? If "Yes", please give details of the conditions in the table below.*
- Yes
- No
PATIENT 1
Full Name*
Condition / Diagnosis*
Medication*
Currently Receiving Treatment*
Date of Last Treatment / Hospitalisation*
YYYY dash MM dash DD
Healthcare Provider Name*
Healthcare Provider Telephone*
PATIENT 2
Full Name
Condition / Diagnosis
Medication
Currently Receiving Treatment
Date of Last Treatment / Hospitalisation
YYYY dash MM dash DD
Healthcare Provider Name
Healthcare Provider Telephone
ADDITIONAL HEALTH STATEMENT INFORMATION
Additional Information

DOCUMENTS REQUIRED FOR REGISTRATION
WHO THIS APPLIES TO	DOCUMENT/S REQUIRED AS PROOF
Your spouse	Marriage Certificate
Your living-in partner	Proof of Dependency Affidavit stating how long the couple have been living together, which is signed and stamped by a Commissioner of Oaths
Your adopted child / child placed in custody of Principal member or their spouse or living-in partner	Copy of the abridged birth certificate Proof of legal adoption Proof of custody
Your or your spouse or living-in partner's biological or natural child (including stepchildren)	Copy of the birth certificate, or hospital confirmation reflecting baby's name (for newborns)
A cild dependant due to disability	Medical report as proof of disability
A child dependant student (up to 25 years of age)	A dependant who is up to the age of 22 A dependant up to the age of 25 provided that the Principal Member submits proof of studies, e.g., written proof of registration for this dependant

Note: You only need to upload a document if it is applicable.
Marriage Certificate
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
Proof of Dependency Affidavit
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
Copy of the Abridged Birth Certificate
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
Proof of Legal Adoption
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
Proof of Custody
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
Copy of the Birth Certificate
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
Hospital Confirmation reflecting Baby's Name
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
Medical Report as Proof of Disability
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
Proof of Dependant's Age
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
Proof of Student Registration
Accepted file types: pdf, doc, docx, jpg, Max. file size: 2 MB.
DECLARATION BY PRINCIPAL MEMBER

1.	I, the undersigned, hereby apply for myself and my nominated dependants to sign up for Liberty Health Cover.
2.	I understand that this application, together with any supporting documents and the Liberty Health Cover Policy Conditions, form the basis of my contract with the Insurer.
3.	Declaration in respect of my partner (if applicable): I confirm that my partner and I are in a committed relationship akin to a marriage based on mutual dependency and a shared household.
4.	Liberty Health Cover Policy Conditions and benefits
	a.	I agree that I and my dependants will be bound by the Liberty Health Cover Policy Conditions and will abide by them.
	b.	The Insurer shall not be bound in any way by any representations or undertakings made or given by any person save as contained in the Liberty Health Cover Policy Conditions.
5.	Exclusions
	a.	I understand that the Insurer may impose exclusions in respect of myself and / or any of my nominated dependants.
	b.	I accept any such exclusion that may be imposed in terms of the Liberty Health Cover Policy Conditions.
6.	Banking Details
	a.	I agree to advise the Insurer in writing of any changes to my banking details.
	b.	I understand that failure to do so will result in me being liable for any subsequent banking charges or other costs / losses incurred due to the use of the incorrect banking details.
7.	Premiums and amounts owed to the Insurer
	a.	I hereby acknowledge that any credit extended by the Insurer to myself in terms of the Liberty Health Cover Policy Conditions will become payable in full by the end of the benefit year in which it arose and that interest may be charged on all amounts due and owing to the Insurer.
	b.	I acknowledge that it remains my responsibility to ensure that any amounts due by me to the Insurer are paid to the Insurer.
	c.	I agree that any amounts owing by me may be off-set against any benefits or payments that may be due to me by the Insurer.
	d.	I also accept that I will be responsible for any costs associated with the recovery of any debts.
8.	Disclosure of information
	a.	I confirm that I have the necessary authorisations to disclose the information that the Insurer may require and provide the necessary authorisations in respect of my nominated dependant/s.
	b.	I confirm that the information provided in this application, and in any other documents submitted in support of this application, is true, correct and complete and that I have not withheld, concealed or misstated any information.
	c.	I furthermore confirm that I understand that my membership will become null and void should the above statement be found to be incorrect and that in such an event, all monies paid in respect of my membership shall be forfeited and that the Insurer shall furthermore be entitled to recover any amounts paid for services rendered from the provider and/or myself.
	d.	I undertake to promptly advise the Insurer of any change in status of health of myself and any of my nominated dependants that occurs prior to the date of registration with the Insurer and acknowledge that the additional information may be subject to underwriting. I acknowledge that not doing so may lead to the Insurer reconsidering the basis of my membership application.
	e.	I indemnify the trustees, agents and administrator of Liberty Health Cover against any claim, of whatever nature, which may be made against them as a result of or arising out of the disclosure of any medical information in fulfilling this agreement.
	f.	I irrevocably authorise any medical practitioner, hospital, medical institution or other person to disclose information about my own, or my nominated dependants’ health status to the Insurer or any entity contracted by the Insurer in order to fulfil its functions, duties and obligations in terms of this agreement and I agree that this authorisation shall remain in force after my/their death/s.
	g.	I irrevocably authorise the Insurer to collect, process and share my personal information and that of any nominated dependants/s with any entity contracted by the Insurer in order to fulfil its functions, duties and obligations in terms of this agreement. I agree that this authorisation shall remain in force after my/their death/s and understand that this may partially limit my/their right to privacy.
9.	Resignation
	a.	I hereby acknowledge that any credit extended by the Insurer to myself in terms of the Liberty Health Cover Policy Conditions will become payable in full upon cancellation of my Liberty Health Cover with the Insurer and that interest may be charged on all amounts due and owing to the Insurer.
	b.	I further acknowledge that on resignation of my Liberty Health Cover, any amounts owing to the Insurer will be deducted from any amounts due to me.
	c.	I confirm that I and all my dependants will cease our current health insurance cover prior to participating in Liberty Health Cover.
10.	Personal contact
	a.	I consent to the use of any of the contact details given in this application to send me information pertaining to my Liberty Health Cover (confidential or other).
	b.	I undertake to inform the Insurer of any change of address and contact details. The Insurer shall not be held liable as a result of my neglecting to inform the Insurer of any changes to the aforementioned.
	c.	I consent to my telephone conversations with the Insurer being recorded and forming part of the Insurer’s records. I also agree that such records shall remain the sole property of the Insurer.
11.	In order to keep you updated on activities about Liberty Health Cover (LHC), we would like to communicate with you, where necessary, via email, SMS or post.

Do you wish to receive LHC marketing communications?*
- Yes
- No
If yes, how would you like to receive them?*
- Email
- SMS
- Post
I consent to LHC marketing products, services and special offers being sent to me from time to time.*
- Yes
- No
I consent that any Third Party contracted to perform services relating to Liberty Health Cover may contact me from time to time regarding their products, services and special offers.*
- Yes
- No
Declaration*
- I hereby declare that I have read, that I understand and that I shall abide by this declaration.

Application Form (Group)