Get a free Health Saver account!

Health Saver is designed to help you plan and provide for healthcare expenses not covered by your Medical Scheme option. All Momentum Health members now automatically qualify for a Health Saver account Health Saver attracts no administration fees so you enjoy the full value of every rand you contribute Health Saver pays interest on positive balances of more than R5 000 You do not have to pay money into your Health Saver, it could simply be where you receive your HealthReturns If you wish to provide for additional day-to-day healthcare expenses by contributing monthly to your Health Saver account, YOU get to choose how much, and can easily change that amount Health Saver is seamless whether you are paying for vitamins, a pedometer, fitness assessments or other medical expenses

Tick this box if you want your free Health Saver account to be activated Start contributing to your Health Saver
To contribute monthly, simply complete your chosen amount below: Monthly amount: R
Minimum of R100 per month

If you do not wish to start contributing to Health Saver at this point, simply complete the Member Details section overleaf and fax to 031 580 0430 together with copies of your ID and a recent utility bill.

Momentum will deduct your monthly Health Saver contributions from the bank account that is used to refund your Momentum Health claims. Should you wish to use a different bank account, please contact the member call centre on 0860 11 78 59.You can also contribute a lump-sum whenever you choose to.

Apply for Credit

If you choose to have a credit facility, you will have access to the annual value of the monthly amount you have chosen above. Tick this box if you want to apply for credit on the amount above, and complete below

Credit assessment inventory

Joint gross monthly income subtotal: Joint monthly household expenses: a) Discretionary expenses (e.g. movies, eating out ) b) Contractual expenses (e.g. car repayments, retail accounts) Expenses subtotal: Net monthly income: R R R R R

Credit provider information

In terms of the regulations of the National Credit Act 34 of 2005, the following information must be supplied. NCR number Name of credit provider: Physical Address: NCR CP 173 Momentum Group Limited 268 West Avenue Centurion Gauteng 0157 0860 11 78 59 (Weekdays 08:00 to 17:00)

Contact number

Terms and conditions

1. 2. I, the undersigned (the Investor), agree to be bound by the rules and conditions applicable to the Health Saver and the terms and conditions of the Loan Agreement as set out in the Rules and Conditions. I hereby appoint Momentum as my agent for the purpose of collecting and depositing all contributions in respect of the Health Saver with FNB Corporate, and I: Confirm that, in doing so, Momentum acts as my agent; Assume, except insofar as there may be a right of recovery against Momentum, all risks connected with the administration of the entrusted funds by Momentum, as well as the responsibility to ensure that Momentum executes the instruction as recorded herein; Agree that I shall direct all enquiries and instructions in respect of the Health Saver to Momentum.

Credit granting for applications

1. 2. 3. 4. 5. I confirm that the above information is true and complete. I understand that the information provided under the Credit Assessment Inventory will yield a Net income figure and that this will determine whether credit will be granted. I understand that the maximum credit I can qualify for is R18 000. I agree that ad-hoc contributions and rebates will not affect the credit advanced to me. I agree that my application is subject to verification, processing and screening and that Momentum may decline an application based on these checks. In addition I give consent that upon acceptance my application will still be subject to continuous screening which may lead to the termination of my application when necessary. I understand that credit granted will be subject to a variable interest rate.

6.

Member Details
Please complete your member details, sign below and fax to 031 580 0430 together with copies of your ID and a recent utility bill. Momentum Health membership number Name Signature of investor (member) Date
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Employer Approval
If your employer will be paying your Health Saver contributions, we need this section to be completed by the authorised representative of your company. Name and surname of authorised person Designation Signature of authorised signatory Employer stamp

Date

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