Pukwanaya Kganya

Claim Form

The Member is our most important asset. As a group, they loyally support Kganya by paying contributions regularly in the knowledge that one day a claim will be submitted. That day has now arrived and you as claimant deserve to be assisted in the most efficient and sympathetic way.

It is our duty as Kganya to make sure that the claims process is as smooth and simple as possible. This Pukwana ya Kganya Dread Disease Claim Form has been created with this in mind.

Please accept our sympathy for your ill health. If you follow the process closely we will be able to guide you through this stressful time.

DREAD DISEASE

Z ION C HRISTIAN C HURCH

June 2017

TO COMPLETE THE CLAIM FORM1. All the information required on the form must be provided accurately.2. The claim form must be accompanied by originals or certified copies of: • The Member’s contribution booklet, • A Medical Report, • The Member’s Identity Document, • Verification of the bank account number and branch code for the Member / beneficiary in the event that EFT claims payment option is selected.3. Kganya Insurance Administrators (Pty) Ltd (RF) reserves the right in all cases to call for additional information where necessary to settle a claim.4. The Church Committee member completing the form must remember: • The Member must be in good standing, that is have paid a contribution in each of the 3 consecutive calendar months preceding the calendar month in which the Member was first diagnosed as having contracted, experienced or suffered a Dread Disease. • The beneficiary is the Member. • At least 3 members of the Church Committee must sign the form. • The Church Committee should always contact Kganya Insurance Administrators (Pty) Ltd (RF) office for assistance.

The form must be taken in person together with all the required documentation to one of the following Kganya Service Centres:

DREAD DISEASE CLAIM NOTIFICATION FORMIMPORTANT

AN OFFICIAL CLAIM FORM MUST BE COMPLETEDFOR EACH CLAIM AND SIGNED BY AT LEAST 3 COMMITTEE MEMBERS

PRETORIA1249 Francis Baard StreetHatfield0083PO Box 11929Hatfield 0028Tel: 010 350 0500Fax: 087 233 0003

JOHANNESBURG1st Floor357 Rivonia BoulevardRivoniaPO Box 2876Rivonia 2128Tel: 011 234 3448Fax: 011 234 3408

NELSPRUIT509 Kamkholo BuildingCnr Brown & Voortrekker St,Nelspruit 1200PO Box 16386Nelspruit 1200Tel: 013 753 2195Fax: 013 752 8205

VRYBURGOffice No 3,Wie-cla CentreCnr Market & Molopo Str.Vryburg 8600Tel: 053 927 3229Fax: 053 927 3524

MTHATHTANo. 8, LCM Ludidi Building, 63 Madiera Street, Mthatha, 5099Tel: 047 531 0039Fax: 047 531 0039

THOHOYANDOUOffice No 2, Ndou MallCnr Tshanduko & Thulamela Str.Thohoyandou 0950Tel: 015 962 5456Fax: 015 962 6076

TZANEEN19 Danie Joubert St.Tzaneen 0850PO Box 3494Tzaneen 0850Tel: 015 307 6887Fax: 015 307 3499

POLOKWANE26 General Joubert StreetPolokwane 0699Private Bag X9542Polokwane 0700Tel: 015 291 5182Fax: 015 291 3005

RUSTENBURGOffice No 1 Five EFS BuildingCnr Berg & Oliver Tambo StreetsRustenburg 0299Tel: 014 592 0505Fax: 014 592 0226

WELKOM1st Floor, ABK CentreHeeren StreetWelkomPO Box 795Welkom 9460Tel: 057 357 1056Fax: 057 357 1057

BURGERSFORTOffice No 1, 1st Floor,Maphutha Ditshaba BuildingCnr Eddie & Church Streets,BurgersfortPO Box 3079 Burgersfort 1150Tel: 013 231 7650Fax: 013 231 8640

MOKOPANEOffice No. 16 & 1742 Retief StreetMokopane 0601PO Box 502Mokopane 0600Tel: 015 491 7651Fax: 015 491 7079

BUSHBUCK RIDGEBushbuckridge Shopping CentreOffice No. 6ACnr Main Bushbuck & Graskop Road, Bushbuckridge, 1280Tel: 013 799 0005Fax: 013 799 0006

GIYANIShop No. 28Masingita PlazaCnr Malamulele &Main RoadsPO Box 4275Giyani 0826Tel: 015 812 0673Fax: 015 812 0674

GROBLERSDAL7 Kruger Street, ext 2GroblersdalPO Box 1438Groblersdal 0470Tel: 013 262 3013Fax: 013 262 5054

KLERKSDORPRoom 311ADanfor Medical CentreJersich Street No. 1OR Tambo StreetPO Box 14362Flamwood Walk 2535KlerksdorpTel: 018 462 6009Fax: 018 462 6108

KGANYA INSURANCE ADMINISTRATORS (PTY) LTD (RF)Authorised Financial Services Provider

DREAD DISEASE CLAIM NOTIFICATION FORM

Kganya Claim Number:

SECTION 2: TO BE COMPLETED BY CHURCH COMMITTEE

The person shown in Section 1A: Yes No

Is the following person known to the Church Committee?:

It is certified by the following Church Committee members that the information in Section 1 and Section 2 is to the best of our knowledge and belief true and correct. At the date of the diagnosis the person shown in Section 1A was a Member in good standing of ZCC and has been approved by the Committee as the beneficiary.

IMPORTANT: In all cases the final decision as to whether or not to admit a claim rests with Kganya Insurance Administrators (PTY) Ltd (RF) as intermediary.

A: PARTICULARS OF MEMBER:

SECTION 1: TO BE COMPLETED BY MEMBER

Member’s First Names:

Member’s Surname:

Member’s ID Number:

Member’s Book Number: Contact Number:

Church Code No: Church Name:

Date: Member Signature:D D M M Y Y

What is the nature of the Dread Disease?:

Date of first diagnosis: D D M M Y Y

I hereby declare that I am the Member and that the answers given to the questions are true and correct in every respect and made without reservation. I authorise any hospital, physician or other person who has attended to myself to furnish Kganya Insurance Administrators (Pty) Ltd (RF) or its representatives any and all information with respect to any sickness or injury, medical history, consultation, prescription or treatment and copies of all hospital or medical records. I confirm not having withheld any information which could be material to the assessment of this claim.

Name: D D M M Y YSignature:

Name: D D M M Y YSignature:

Name: D D M M Y YSignature:

Is a Medical Report attached?: Yes No

B: CLAIM DOCUMENTS CHECKLIST:THESE DOCUMENTS ARE REQUIRED TO FINALISE YOUR CLAIM:

Required Included

COMPLETED DREAD DISEASE CLAIM FORM To be obtained from Church Committee and completed with their assistance. Requires the signature of at least 3 Church Committee members.

PUKWANA YA KGANYA MEMBERSHIP BOOK Required in all cases.

ID BOOK OF MEMBER OR CERTIFIED COPY Required in all cases.

BANK STATEMENTS OR PROOF OF BANK ACCOUNT Required where EFT payment option is selected by the Member.

COMPLETED DREAD DISEASE MEDICAL REPORT FORM To be obtained from Church Committee and completed by a medical specialist. The form must be fully completed.

SECTION 3: TO BE COMPLETED BY SERVICE CENTRE MANAGER

Were any of the Receipts shown above purchased on or after the date of diagnosis? Yes No

Show Receipts from Membership Book ending with the last sticker purchased prior

to date on which the Dread Disease was first diagnosed

Type: Number: Date sold by Church:

I confirm that: (1) other than as set out above, all claim documentation has been received and is correctly completed (2) the receipts specified above are inserted in the Membership book of the Member specified in Section 1A

Bank Account Number / Benefit Card Number / Cheque Number :

A: DETERMINATION OF GOOD STANDING:

Claim is APPROVED for payment (complete Section 3C)

Claim is PENDING

Claim is REPUDIATED (complete Section 3B)

C: DECLARATION BY MEMBER:

I, being the undersigned Member in respect of the claim referred to above confirm that all of the information provided by myself, including any amendments made above by the Service Centre Manager, are to the best of my knowledge correct. I confirm that I have:

Is all the claim documentation including Dread Disease Claim Notification Form held and correctly completed? Yes No

D D M M Y YDate:Service Centre:

Missing and/or incomplete Claim documentation

Claimant has requested the following payment option: EFT Cheque Benefit Card

D D M M Y YDate:Signed by Member:

D D M M Y YDate:Signed by Service Centre Manager:

I have informed the Member that the claim has been repudiated by the underwriter in terms of the master Policy on the basis set out in the Claim Repudiation Notice, a copy of which has been handed to the Member.

B: TO BE COMPLETED WHERE THE CLAIM IS REPUDIATED:

D D M M Y YDate:Signed by Service Centre Manager:

D D M M Y YDate:Signed by the Member:

Received Cheque/Card Number: For: in settlement of the claim.R

Requested EFT payment: For: in settlement of the claim.R

D D M M Y YDate:Signed by the Member:

Pukwanaya KganyaMedical Report

The Member is our most important asset. As a group, they loyally support Kganya by paying contributions regularly in the knowledge that one day a claim will be submitted. That day has now arrived and you as claimant deserve to be assisted in the most efficient and sympathetic way.

It is our duty as Kganya to make sure that the claims process is as smooth and simple as possible. This Pukwana ya Kganya Dread Disease Medical Report has been created with this in mind.

Please accept our sympathy for your ill health. If you follow the process closely we will be able to guide you through this stressful time.

DREAD DISEASE

Z ION C HRISTIAN C HURCH

Apri l 2017

MEDICAL REPORT DREAD DISEASE

I, the undersigned, a registered Medical Specialist, whose name appears below, certify the following facts in respect of the under mentioned Patient.

A: PATIENT DETAILS:

B: MEDICAL DETAILS:

Member’s First Names:

Member’s Surname:

Member’s ID Number:

TO BE COMPLETED BY A MEDICAL SPECIALIST

Is the Patient’s dread disease related in any way to any of the following?

Heart Attack? YES NO

If so, was the heart attack supported by:

• A history of typical chest pain? YES NO

• New ECG changes diagnostic of myocardial infarction? YES NO

• An elevation of cardiac enzymes three times the normal limit? YES NO

Please provide copies of the laboratory reports and ECG’s.

Stroke? YES NO

If so, was the cerebrovascular incident followed by neorological damage which has lasted more than 24 (twenty -four)

hours and is of a permanent nature? YES NO

Please provide copies of the CT/MR/Neurologist/Neurosurgical reports.

Cancer? YES NO

If yes, has the patient contracted cancer with uncontrollable growth and spread of malignant cells, infiltration of normal

tissue or histology of a malignant growth? YES NO

Coronary Artery (bypass) surgery? YES NO

State the type of procedure undertaken and date performed.

Total kidney failure? YES NO

If yes, is this condition classified as end stage renal failure presenting as chronic irreversible failure of both kidneys to

function as a result of which renal dialysis is instituted? YES NO

Major Organ Transplant? YES NO

What were the events predisposing the surgery?

What organ was replaced?

What was the underlying cause?

For how long was the disease present?

What was the source of the replacement?

PLEASE NOTE THAT THE BELOW INFORMATION IS MATERIAL AND ALL QUESTIONS SHOULD BE ANSWERED ACCURATELY AND COMPREHENSIVELY

Blindness? YES NO

Was the blindness caused by disease? YES NO

If yes, which disease?

Please provide all specialist reports and investigations done including a visual acuity reading.

Coma? YES NO

Please provide all specialist reports, Glasgow Scale score and clinical notes confirming period of unconciousness

and details of mechanical ventilation.

Multiple Sclerosis? YES NO

Have the following neurological investigations been done:

• Lumber puncture? YES NO

If yes, please give date of procedure and attach results Date:

• Evoked visual responses? YES NO

If yes, please give date of procedure and attach results Date:

• Evoked auditory responses? YES NO

If yes, please give date of procedure and attach results Date:

• MRI Scan? YES NO

If yes, please give date of procedure Date:

• Was there evidence of any lesion of the central nervous system? YES NO

If yes, please attach results from the scan

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

C: GENERAL:

Please supply relevant ICD codes

When was the Dread Disease first Diagnosed? Date:

When did the symptoms first appear? Date:

Please confirm date of diagnosis of the above contributing factors Date:

When did the patient first consult you in this regard? Date:

Date of most recent examination of the patient Date:

Has the patient suffered from the same or similar condition? YES NO

If yes, give full details

What are the contributing factors?

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

D: DETAILS OF MEDICAL SPECIALIST:

Name:

Qualifications:

HPCSA number:

Practice Number:

Telephone Number:

D D M M Y YDate:Signature:

APRIL 2017

Certification stamp