When completed please send to:

[email protected]
or Whatsapp: 0720366744
Individual application for membership
Important notes:
• AGS Health (Pty) Ltd (hereon forward referred to as AGS Health) is not a medical
scheme registered under the Medical Schemes Act, 131 of 1998.
• AGS Health is a registered medical insurance product underwritten by African Unity Life.
• Please do not resign from your current medical scheme/insurer until you have received
written notification of acceptance from AGS Health.
• Please ensure that the first name and surname of the principal member, spouse
and dependents are completed in accordance with the ID or passport.

Cover may only commence on the first day of a nominated month. Which month would Choose which month
you like cover to commence? _______________________________________________ you'd like to start
Section 1: Member’s Details:
Principal Member’s Details:
Title: Initials: First name:
Surname:
Previous surname:
ID/Passport number:
Country in which passport was issued:
Gender: Male Female Date of birth: Y Y Y Y / M M / D D
Country of residence:
Marital status: Single Married Separated Divorced Widowed
Home address:
Postal code:
Postal address: (if different)
Postal code:
Contact Details:
Home: - Cellular:
Email address:
Please note that the email address you provide will be used when AGS Health communicates with you.
Occupational Details of Principal Member:
Occupation:
Agriculture, Food and Natural Resources Hospitality and Tourism
Architecture and Construction Human Services
Arts, Audio/Video Technology and Communications Information Technology
Business Management and Administration Law, Public Safety, Corrections and Security
Education and Training Manufacturing
Finance Marketing, Sales and Service
Government and Public Administration Science, Technology, Engineering and Mathematics
Health Science Transportation, Distribution and Logistics
Income Level:
R4 000 to R12 000
R12 000 to R20 000
R20 000 to R28 000
R28 000 to R36 000
R36 000 above
Spouse or partner (If spouse or partner is also applying for membership)
Title: Initials: First name:
Surname:
Previous surname:
ID/Passport number:
Gender: Male Female Date of birth: Y Y Y Y / M M / D D
Dependents:
Full Names Surname Relationship to member ID number / Date of birth
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Section 2: Medical Questions:
Medical History questions
Failure to disclose a medical illness or injury that you or your dependents have before taking this policy, could limit and or exclude certain
benefits or result in termination of your membership.
Have you or your dependents had any of the following:
2.1.1 Cancer, tumors, and abnormal growths e.g., cancerous tumor; non-cancerous Yes No
tumor; blood cancer
Name of Member Condition Year of diagnosis Treating Doctor

2.1.2 Blood conditions Yes No

Name of Member Condition Year of diagnosis Treating Doctor

2.1.3 Metabolic and endocrine conditions e.g., diabetes; thyroid issues; osteoporosis Yes No
Name of Member Condition Year of diagnosis Treating Doctor

2.1.4 Brain and nerve conditions e.g., epilepsy; headaches, Parkinson Disease Yes No
Name of Member Condition Year of diagnosis Treating Doctor

2.1.5 Eye and eyelid conditions e.g., Cataracts; glasses; corneal ulcer Yes No
Name of Member Condition Year of diagnosis Treating Doctor

2.1.6 Ear, nose, and throat conditions e.g., hearing problems; chronic tonsillitis; sinus Yes No
problems
Name of Member Condition Year of diagnosis Treating Doctor

2.1.7 Heart and circulation problems e.g., high blood pressure; chest pain; high Yes No
cholesterol
Name of Member Condition Year of diagnosis Treating Doctor

2.1.8 Breathing and lung conditions e.g., Asthma; emphysema, clot (s) in the lung Yes No
Name of Member Condition Year of diagnosis Treating Doctor
 2.2.9 Stomach and digestive conditions e.g., Gall stones; heartburn; hernia Yes No
Name of Member Condition Year of diagnosis Treating Doctor

2.2.10 Back, bone and muscle conditions e.g., Arthritis; back pain; lupus Yes No
Name of Member Condition Year of diagnosis Treating Doctor

2.2.11 Kidney and bladder conditions e.g., Kidney Stones; urine retention; Yes No
bladder infection
Name of Member Condition Year of diagnosis Treating Doctor

Member (Male) 2.2.12 Did you or any of your dependents have a historical Yes No
abnormal PSA test or prostate infections?
Member (Female) 2.2.13 Gynecological issues, abnormal pap smear; cysts on Yes No
the ovaries; endometriosis
Name of Member Condition Year of diagnosis Treating Doctor

2.2.14 Are you or any of your dependents currently pregnant? Yes No

Name of Member How many weeks Treating Doctor

Section 3: Plan Option choice

Combination Plans
Green Combo Blue Combo Red Combo
Compact Plan
Day 2 Day Only
Green Day 2 Day Blue Day 2 Day Red Day 2 Day
Hospital Plan Only Emergency Plan Only Hospital & Emergency
Funeral Plans
10 000 Single Plan 20 000 Single Plan 30 000 Single Plan
10 000 Family Plan 20 000 Family Plan 30 000 Family Plan
Dental Plans
Bronze Dental Plan Gold Dental Plan
Silver Dental Plan

TICK ONE BOX

Section 4: Banking details for Debit Order
Tick here if we may use the same bank account details provided for your AGS Health Claim refunds
If not, please complete the bank details below.
(Please do not provide credit card details. AGS Health is not allowed to record your credit card details)
Name of account holder:
ID No. of Account holder:
Name of bank:
Account number:
Account type: Current/Cheque: Savings:
Branch code:
Debit order Date: Y Y Y Y M M 0 1
Please note that you, as the principal member, need to sign this section, if somebody else’s bank account details have been
provided.

PLEASE NOTE: A resolution is required (authorisation/approval) by the shareholders of the company in the case where a
company account will be used.

Debit Order Mandate:

We authorise Qsure to draw against our bank account the contracted value in terms of an authority/mandate from insurers to
collect and manage monies in respect of insurances in addition to other value-added products for which we extend the authority
to collect by debit order. We further authorise EPIC to increase or reduce such amounts due from time to time to reflect any
change including changes in cover risk sum insured or premium rates. We understand that the withdrawals hereby authorised
will be processed through a computerised system provided by the south African banks and we also understand that details of
each withdrawal will be printed on the bank statement with the reference prefix AGS Health and will be followed by your policy
or agreement. This authority remains in force until cancelled in writing by us or the beneficiary.

Signature of principal Member Date Signature of account holder Date

 Section 5: Consent for AGS Health to process personal information
5.1 I declare to the best of my knowledge and believe that the given particulars are true and correct.
5.2 I am satisfied that the plan chosen by me suite my needs.
5.3 I can afford the monthly premium of the plan chosen by me.
5.4 I have chosen this plan purely out of free will and on my own account without the request for a financial need’s analysis or financial
advice from any person.

AGS Health and the Administrator are committed to maintaining the confidentiality of your personal information and complying with the
Protection of Personal Information Act, 2013 when processing your personal information. We request your consent to process your personal
information and obtain your personal information from any other person for the purposes set out in this section. While your consent is
voluntary, it is a requirement for your membership.
1. The personal information we require relates not only to you but also to your child and adult dependents, and you confirm that you
are authorised to provide consent in this section on behalf of your dependents on AGS Health.
2. You authorise, and give consent to, AGS Health and the Administrator to collect, store, collate, process, share and further process
your personal information, including health information, and that of your dependents, for purposes of your membership of AGS
Health, risk profiling and management and as set out in this section.
3. If you have consented to the disclosure of your personal information to any other entity or person (person means any natural or
juristic person, firm, company, corporation, state, agency or organ of a state, association, trust or partnership, whether or not having
legal personality) or if a contractual relationship exists between AGS Health or the Administrator which requires AGS Health or the
Administrator to provide your personal information to any other person AGS Health or the Administrator may do so.
4. You must give AGS Health and the Administrator all information and evidence they may require from time to time for the purposes of
assessing this application, your membership of AGS Health, risk profiling or management. You authorise AGS Health and the
Administrator to obtain, from any person, including any medical doctor or other healthcare provider who has attended you or your
dependents in the past or who will attend to you or your dependents in the future, any information we may require concerning you or
any of your dependents in assessing any risk or claim in relation to this application, your membership of AGS Health, risk profiling or
management and you consent to that person providing, and instruct that person to provide, AGS Health and the Administrator with
this information on request. You waive the provisions of any law or regulation that restricts the disclosure of this information. You
must also submit to any examination by AGS Health’s medical assessor as and when AGS Health requires this.
5. You understand that your personal information will be shared between AGSHealth, the Administrator and contracted third parties both
locally and outside the Republic of South Africa who require this information, for purposes related to your membership of AGS Health
and:
• to grant you access to interact with AGSHealth on its website; and
• to provide any credit bureau or registered credit provider with your credit information as defined in the National Credit Act, 2005
(credit information includes, for example, my credit history, financial history, pattern of payment or default under any credit
agreements, debt re-arrangement arrangements or judgments obtained for outstanding debts).

Signature of principal member Date

Section 6: General Terms and Conditions

DISCLOSURES:
I warrant that I have taken note and understand the cover limits, waiting periods and the limitations of this policy. Should there be any dispute as
to the information provided, the policy wording that that forms part of the Welcome Pack will be deemed to be correct and will be the basis of this
agreement. In no way do I expect that the policy will provide unlimited cover in the event of medical occurrences unless expressly indicated as
such. This is an application for a binding insurance contract on the intermediary and myself and no further acceptance of terms and conditions or
any other documents will be necessary for this contract to become binding. I fully understand that the AGS Health Policy is based on insurance
cover and is not a medical aid and that the policy is a month-to-month contract. The cover in this policy has no s urrender/cancellation/maturity
values and in the event that my premium is unpaid, the cover applicable to the policy will lapse, subject to the grace period offered by the
Administrator being AGSHealth. I further declare that all the information entered by me on this application is true and correct and should any
further information be required I will make this available to the Administrator or Insurer as necessary for my policy or any query related to the
policy. The disclosure of medical conditions is true and correct, and I am in no way entering this agreement with the knowledge of undisclosed
conditions or expected future conditions. The policy wording necessary for this policy to be binding on the parties will be made available to me
through communication by the Administrator. PAYMENT OF COVER: I accept that the payment of any cover due to a valid claim will first be paid
to the Administrator trust account held in my name, for distribution to the service providers who have presented valid invoices for services
rendered to a beneficiary of this policy. I understand and accept that after these payments have been made only the remaining portion of the
claim will be paid to me, the principle insured of this insurance product. I hereby issue power of attorney and a mandate to AGSHealth to act on
my behalf for each and every claim. I understand that no additional charge will be levied against me for the services offered in assisting me with
my claim.
ACCEPTANCE:
The Administrator will advise me of the acceptance of the terms of the above policy and if there are any terms and conditions that require
additional disclosure for my individual policy.
ITC RATING CHECK:
I authorise the Administrator to submit my details to ITC to properly rate my account and credit record. The Administrator warrants that all
information received from ITC in this regard will be treated as confidential and will not be disclosed to any third parties.
PREMIUM INCREASES/POLICY AMENDMENTS:
The Administrators reserve the right to increase premiums or amend the policy cover at their discretion. Notice of any premium increases or cover
amendments will be given in writing 31 days (one calendar month) before any such changes come into effect.
PREMIUM REFUNDS:
Should a policy be cancelled in writing within the first 31 days of the date of application (cooling off period), the premium will be refundable if it
has been deducted from my nominated bank account. If the policy is cancelled after the 31 days cooling-off period, a one calendar month written
notification period will apply and the policy will only be cancelled 31 days after the first day of the following month. I understand that my premium
will only be refunded 31 days after it has been deducted and I may need to submit supporting documentation before any refunds are granted.
CANCELLATIONS:
Cancellations requested after the inception date are subject to a full calendar month notice period and should be in writing.
TERMS AND CONDITIONS:
By accepting this product, you are confirming that is appropriate and in accordance with your needs. Please note it’s your responsibility to take
care as to the appropriateness of the advice given. You were not provided with full comprehensive advice. Please note that there was no one that
compared our product with any other competing product. You have been presented with a product of AGS Health only. Should this product
replace a current policy fulfilling the same need, you will need to cancel that policy timeously to avoid paying fees and charges twice.
Please be informed that there are waiting periods and exclusions that apply. Please refer to the policy document which you will receive within 2
business days. It is your responsibility as a client of AGS Health to read the policy and understand the policy.
We receive 3.25% commission and 9% Binder Fee from African Unity Life which equates to 100% of total commission received.
Should you miss your monthly payment due, your policy will be suspended. Should you miss two payments, your policy will lapse.
PAYMENT INSTRUCTIONS:
I hereby authorise AGS Health Ltd or appointed collection agent namely Insure Group Managers LTD t/a Epic, to deduct premiums, excess
amounts or any amounts are per the policy wording or terms and conditions of the parties. I acknowledge that failure / rejection of said debits
may result in my policy being suspended or cancelled. I agree that all payment instructions issued by the underwriter will be treated by my
nominated bank as specified in Section 9 of the application, as if the instruction has been issued by me personally.
PAYMENT:
I hereby agree and authorise the account specified in Section 9 of the application to be debited every month with the premium amount starting on
the inception date or the next business day. The inception date is deemed to mean the next occurrence of the date chosen. Should this date have
passed, the policy inception date will fall into the next calendar month. I acknowledge that premiums are collected in advance and not in arrears.
DECLINED / FAILED PAYMENTS:
Will be debited on the next debit order date, or alternatively through a special debit that may be run at any time from the date of notification by
our collection agent of the failed / returned payment as mentioned above. I acknowledge that in the event of declined / failed debits, I may incur
additional bank charges as levied by my bank. Should the payment be returned once, the policy cover will be suspended, and the policy may be
re-dated to begin on the first of the following month. The policy may be suspended but a member has a right to still enjoy the benefits (arrear
premiums can be subtracted from the benefit amount payable). A Grace period of 15 days from Inception Date will apply to this policy. I hereby
grant permission to the Administrator to double debit my account in the event of a rejected payment. If this double payment is returned, no
further attempts will be made to collect premiums and cover will be cancelled with immediate effect.
EXCESSIVE CLAIMS:
I understand that should my claims history be deemed excessive; a policy increase may be levied on my premium. This increase is at the
discretion of the Administrators and subject to a 30 day (one calendar month) written notice period.
HEALTH LOADING:
I accept and understand that pre-existing conditions (known or unknown) may be excluded and/or may increase my monthly contribution.
POLICY DELIVERY:
The policy documents, membership cards (if requested), policy guides and associated documents will be sent out within thirty days after the
successful collection of my first premium. The information in the policy wording as well as in all declarations made will form the basis of the
contract, and it is warranted by AGS Health that such information is accurate. This policy, however, shall not be invalidated on account of any
incorrect statement made in good faith, unless the incorrectness of such statement is of such a nature as to be likely to have materially affected
the assessment of the risk under the Policy at the time the policy was issued.
GENERAL CONDITIONS AND EXCLUSIONS:
An Insured Person may not be covered for more than one Policy under this insurance category.
If at the time of any Insured Event, giving rise to a Medical Expenses claim under this policy an Insurance or Medical Aid Scheme exists with any
other Insurers or Medical Aid covering the Insured Person against the defined events, the Insurer shall be liable to make good only a rateable
proportion of the amount payable by or to or on behalf of the Insured Person in respect of such Insured Event.
The Policyholder will not be entitled to any benefits if admission is required for the purposes of investigative procedures or any other investigation
only, unless specifically provided for in this agreement.
The Insurer will not be liable for any claims:
 was caused by suicide or attempt thereat or self-inflicted injury or willful exposure to danger (unless in an attempt to save human life);
 in respect of expenses arising out of routine physical or other examinations where there is no objective indications or impairment in normal
health;
 in respect of obesity, elective, elective cosmetic or plastic, corrective optical and laser surgery or treatment and costs resulting therefrom
except in the case of bodily reconstruction as a direct result of an Injury sustained in an Accident;
 resulting from an Insured refusing medical treatment recommended by a physician or medical practitioner;
 resulting from an Insured unreasonably or willfully neglecting or failing to seek and remain under the care of a medical practitioner;
 resulting from, whilst in Hospital at the Insured Person’s own choosing which has no connection with any Injury, Illness or Dread Disease or
in Hospital other than by recommendation by a qualified physician;
 resulting from, whilst in Hospital for the investigation of pain and pain related conditions and treatment in this context includes bed rest,
traction, physiotherapy, spinal blocks, medication or intravenous medication;
 where the Insured did not take all reasonable precautions to prevent Accidents and do not comply with all statutory requirements and
regulations;
 was caused by, or as a result of, the influence of alcohol, drugs or narcotics upon such Insured Person unless administered by, or prescribed
by, and taken in accordance with the instructions of a member of the medical profession (other than himself);
 was caused by the use of nuclear, biological, chemical or explosive weapons or arising from exposure to, or contamination by, atomic energy
and/or nuclear fission or reaction;
 if injuries sustained whilst any person driving a vehicle or motorcycle is under the legal driving age, or is not authorized or qualified to drive
such a vehicle or motorcycle;
 was caused whilst travelling by air other than as a passenger and not as a member of the crew nor for the purpose of any trade or technical
operation thereon or therein;
 was caused whilst participating in a hazardous or Professional Sport/activity; was caused by any mental illness, mental disability, mental
impairment and psychopathic disorders, all forms of depression, major affective disorders, psychotic and neurotic conditions, as well as all
stress and anxiety related disorders, other than those caused by Accident as defined in this Insurance;
 while it was caused by mountaineering or rock climbing necessitating the use of ropes or guides, potholing, hang gliding, sky diving, riding or
driving in a race or rally, quad biking, off-road motorcycle riding, underwater activities involving the use of artificial breathing apparatus
unless the Insured Person has an open water diving certificate or is diving with a qualified instructor to a depth no greater than 30 meters
and/or similar activities, unless agreed by the Insurer;
 was caused whilst the Insured Person is perpetrating an intentional unlawful act in terms of South African Law;
 was caused by any gradually operating cause;
 for services rendered to an Insured Person by a person not registered with the South African Medical and Dental Council and/or the South
African Health Professions Council;
If the consequences of an Accident shall be aggravated by any condition or physical disability of the Insured Person which existed before the
Accident occurred, the amount of any compensation payable under this Insurance in respect of the consequences of the Accident shall be the
amount which it is reasonably considered would have been payable if such consequences had not been so aggravated.
In addition to the above, qualified medical advice shall be sought and followed promptly on the occurrence of any Bodily Injury, Dread Disease or
Illness and the Insurer shall not be liable for any part of any claim which in the opinion of the medical adviser arises from the unreasonable or
willful neglect or failure of a Insured Person to seek and remain under the care of a qualified member of the medical profession.
Where an Insured Person is covered in terms of a statutory body such as the Compensation for Occupational Injuries and Diseases or the Road
Accident Fund or their successors in title or assigns, in relation to an Accident, the Insurer will only be liable for amounts that the Insured may be
liable for due to shortfalls incurred and up to the maximum Accident Benefit amount.
No claim will be admitted in terms of this Policy if the event giving rise to the claim is caused directly or indirectly by or is in any way attributable
to any of the following:
 The willing participation by the Principal Insured or such other insured persons under this Policy, in any of the following:
o an act of war (whether war is declared or not);
o military action;
o Riot or unlawful strike
o insurrection;
o civil commotion;
o usurpation of power;
o martial law;
o terrorism; and
o any usage of nuclear, chemical and biological weapons, device or agent.
• A disease, epidemic or a pandemic
• An Act of Government;
• Any act or deed by the Principal Insured deliberately committed in violation of any law as well as any other insured person under the Policy
including but not limited to a minor child, where his/her parent and/or legal guardian knowingly allows such child to participate in any act
which constitutes a violation of any law;
• Self-inflicted injury or self-inflicted illness, whether intended or not, or voluntary exposure to danger or obvious risk of injury. Any injury or
disease which is caused partly by the actions or omissions of the insured, but in conjunction with the action or omission of some other party
of some other contributory factor, will fall outside the ambit of the above exclusion.

Signature of principal member Date