Addition of dependants

form
Ensure that all applicable sections are completed in full, and that you provide all necessary supplementary
documentation. Submit the completed form to GEMS via any of the following channels:
0861 00 4367 enquiries@gems.gov.za GEMS, Private Bag X782, Cape Town 8000

Section A: Main member details

nnn
Initials nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
nnnnn
Surname
Membership no nnnnnnnnnn
Section B1: Details of dependants
No beneficiary may be enrolled with different medical schemes simultaneously
Dependant 1
First name nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Surname nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
ID/Passport no. nnnnnnnnnnnnnn Gender n M n F
Country in which passport was issued nnnnnnnnnnnnnnnnnnnnnnnn
Date of birth nnnnnnnn Mobile no. nnnnnnnnnnn
D D M M Y Y Y Y
Email address nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Relationship with main member nnnnnnnnnnnnnnnnnnnnnnnnnn
Is the dependant factually dependent on main member? Yes n n No
Has the dependant ever been a main member or dependant of GEMS? n
Yes n No
If Yes, provide membership no. nnnnnnnnnn
Is the dependant currently a member or a dependant of another medical scheme? Yes n n No
If Yes, have you given notice of termination to the current medical scheme? Yes*n n No**
*If Yes, please attach a certificate of membership from that medical scheme reflecting the end date of the membership
and any waiting periods that were applied. We cannot finalise your application without this.

**If No, please give the required notice to the current medical scheme before submitting the application, and attach
a certificate of membership from that medical scheme indicating the end date of the membership and any waiting
period that were applied. We cannot finalise your application without this.
Dependant 2
First name nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Surname nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
ID/Passport no. nnnnnnnnnnnnnn n nF Gender M
nnnnnnnnnnnnnnnnnnnnnnnn
Country in which passport was issued
Date of birth nnnnnnnn nnnnnnnnnnn
D D M M Y Y Y Y Mobile no.
Email address nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
nnnnnnnnnnnnnnnnnnnnnnnnnn
Relationship with main member
Is the dependant factually dependent on main member? n Yes n No
Has the dependant ever been a main member or dependant of GEMS? n Yes n No
If Yes, provide membership no. nnnnnnnnnn
Is the dependant currently a member or a dependant of another medical scheme? n Yes n No
If Yes, have you given notice of termination to the current medical scheme? n Yes* n No**
*If Yes, please attach a certificate of membership from that medical scheme reflecting the end date of the membership
and any waiting periods that were applied. We cannot finalise your application without this.

**If No, please give the required notice to the current medical scheme before submitting the application, and attach
a certificate of membership from that medical scheme indicating the end date of the membership and any waiting
period that were applied. We cannot finalise your application without this.

ID/Passport no. nnnnnnnnnnnnn Initial 1 of 7

Provide the details of all the medical schemes that your dependants previously belonged to, if applicable.

Dependant Is the dependant End date if already Reason for

Scheme name Start date
name still a member? resigned leaving

n Yes n No

n Yes n No

n Yes n No

n Yes n No

Please ensure that you enclose the following with your application form:
• Copy of relevant ID.
• An affidavit confirming relationship if surnames are different.
• Legal documentation if child is adopted.
• An affidavit confirming factual dependency if partners are co-habiting, including witnesses.
• Proof of registration at a legally recognised tertiary institution (student card does not serve as proof), if dependant is
over 21. Please note that you will have to pay the adult rate if this report is not enclosed with your application form.
• Medical report confirming disability for a dependant over 21. Please note that you will have to pay the adult rate if
this report is not enclosed with your application form.

Section B2: Medical history and general health information

Failure to disclose pre-existing conditions could limit and/or exclude certain benefits or result in termination of your
membership.

HIV/AIDS
Although you are not obliged to disclose the HIV status of your dependant(s) on this form, you are required, in line
with the Scheme rules and underwriting criteria, to contact our confidential HIV line on 0860 436 736 within seven
working days from the date that you submit your membership application to GEMS, should you be receiving HIV-
related treatment. We want to assure you that we treat this information with the strictest of confidence.

Was medical advice, diagnosis, treatment or care received or recommended in respect of any of your dependants
(excluding newborns and/or newly-adopted children) as per this application form, in respect of any of the following, in
the last 12 months? (Please supply the required information by marking the relevant box with a X.)

1. Do any of your dependants use chronic medicine? YES NO

Disorders or problems with the heart or cardiovascular system, e.g. heart murmur, high
2. blood pressure, high cholesterol, shortness of breath, palpitations, chest pain, angina, heart YES NO
attack and/or any other cardiac or blood disorder.
Respiratory or lung disorders, e.g. tuberculosis, asthma, persistent cough or other
3. breathing problems, emphysema, coughing up blood, cystic fibrosis, sinusitis or allergic YES NO
rhinitis.
Disorders of the digestive system, stomach, gall bladder, pancreas or liver, e.g. gastric
or duodenal ulcer, heartburn, hiatus hernia, rectal bleeding, Crohn’s disease, ulcerative
4. YES NO
colitis, irritable bowel syndrome, hepatitis, cirrhosis, liver failure or have you ever had a
gastroscopy or colonoscopy?
Disease or disorders of the kidneys, bladder or reproductive organs, e.g. abnormal
5. urine tests, kidney stones, nephritis, prostatitis, bladder infections or sexually transmitted YES NO
diseases.
Disorders of the nervous system or brain, e.g. epilepsy, stroke, multiple sclerosis,
6. migraine, headaches, paralysis, Parkinson’s disease or have you or any of your dependants YES NO
been advised to have a MRI or CT scan?

ID/Passport no. nnnnnnnnnnnnn Initial 2 of 7

 Mental disorders, e.g. depression, anxiety, panic attacks, schizophrenia, eating disorders,
7. YES NO
attention deficit hyperkinetic disorder (ADHD) or post-traumatic stress disorder.

Ear, nose, throat or eye disorders, e.g. defective vision, cataracts, glaucoma, retinitis,
8. YES NO
disorders of the cornea, hearing loss, ear discharge, otitis media or allergies.
Disorders or diseases of the skin, muscles, bones, joints, limbs or spine, e.g. any
9. skin rash, arthritis, gout, fibromyalgia, any back/neck/hip/knee or other joint trouble, multiple YES NO
sclerosis, any joint problems or replacements, acne, eczema or psoriasis?
Diabetes, sugar in urine, thyroid or other glandular or blood disorders, e.g. anaemia,
10. YES NO
bleeding disorders, growth disorder, Cushing’s disease or Addison’s disease.

11. Cancer, a growth or tumour of any kind including moles removed (malignant/benign). YES NO

Are any of your dependants currently undergoing or anticipating any specialised dental/
12. YES NO
maxillofacial treatment?

13. Have any of your dependants had any accidents (including motor vehicle accidents)? YES NO

Are any of your dependants taking ongoing medicine for any condition not listed in any
14. YES NO
other question?

15. Have any of your dependants had any surgical procedure? YES NO

Are any of your dependants awaiting or planning any operation or admission to any
16. YES NO
hospital in the next 12 months?
Is there any other condition or symptom, which is not detailed in any other question,
17. for which medical advice, diagnosis, care or treatment has already been recommended or YES NO
received, or could potentially result in a medical claim within the next 12 months?
Gynaecological disorders, e.g. abnormal pap smear or mammogram, endometriosis,
18. ovarian cysts, fibroids, infertility, disorders of the cervix, menstrual disorders or any YES NO
abnormality of pregnancy or confinement.

Are any of your dependants pregnant? If so, what is the expected date of delivery?
19. YES NO
Date:

ID/Passport no. nnnnnnnnnnnnn Initial 3 of 7

If your answer was Yes to any of the above questions, please provide full particulars in the space below. Please use
a separate sheet of paper if the space is not sufficient.

Name of person
suffering from
illness
Question
number
Illness or
condition
Date on which
illness began
Date of last
occurance
Name of treating
doctor
Doctor’s contact
details
Treatment
recommended
(medicine, etc.)
Treatment from
(date)
Treatment until
(date)

Section B3: Acknowledgment of waiting periods

Please note: GEMS will impose underwriting on certain membership categories in the form of waiting periods.
Please declare your acceptance of this by signing below.

• I am aware that GEMS reserves the right to impose waiting periods on any beneficiary (myself or any of my
dependants). GEMS will notify me in writing should any of these waiting periods apply to me and/or any of my
registered dependants, based on the information provided in this application.
• I understand that a three-month general and/or twelve-month condition-specific waiting period may be imposed
on the following membership categories:
• Main members who resign from GEMS with their dependants (without also resigning from the Public Service) and
then re-join GEMS at a later stage.
• Dependants who are resigned from GEMS and who are then re-registered by the main member at a later stage.
• Dependants who join GEMS on a different date from the main member (excluding newborn babies and newly-
adopted children).

Signature of main member nnnnnnnn

Date D D M M Y Y Y Y

Section C: Declaration

I, ID number nnnnnnnnnnnnn
declare that the information submitted is true and correct.

Signature of main member nnnnnnnn
Date D D M M Y Y Y Y

ID/Passport no. nnnnnnnnnnnnn Initial 4 of 7

 Section D: Details of dependant(s)

• It is compulsory to complete the details of the dependant(s) you intend registering as beneficiaries in this section of
the application form. We will be unable to register them if this information is not provided.
• Adult dependant rates are payable for all eligible dependants over the age of 21. Child rates are, however, payable
in respect of dependants under 28 years who are enrolled for any course(s) accepted by the GEMS Board of
Trustees or undergoing supervised practical training, as well as disabled dependants.
• Please note that your adult dependant(s) will be subject to at least an annual eligibility review. Members must
annually provide proof of dependency of all beneficiaries over the age of 21 and may be required to furnish proof of
eligibility, for example proof of student registration.
• The following documentation is required when you apply to register a dependant:

Description of dependant Documentation required

Spouse
Ex-spouse
Partner
Child under the age of 21
(biological, adopted, step, foster
child of the member or the
member’s spouse, or a child who
depends on the main member for
family care and support)
Child of 21 and older
(biological, adopted, step,
foster child of the member or the
member’s spouse, or a child who
depends on the main member for
family care and support)
Parents, step parents, parents-
in-law, step-parents-in-law,
grandparents or grandparents-
in-law
Grandchild, great grandchild
etc.
Sibling, half sibling, step
sibling and in-law sibling
Children of sibling (nieces and
nephews)
• If it is a customary marriage, an affidavit from the member confirming the obligation towards his/
her spouse.
• A marriage certificate is required if married and the surname of the spouse differs from that of the
main member.
• A copy of the spouse’s ID.
• Evidence (example: the Divorce Order) of a legal obligation to provide medical support per
divorce settlement or court.
• A copy of the ex-spouse’s ID.
• A sworn affidavit, confirming that the dependant is the member’s life partner (the affidavit is to be
completed both the main member and partner).
• A copy of the partner’s ID.
• A copy of the child’s ID or birth certificate.
• Note: If the child’s surname differs from the main member’s, an affidavit confirming the obligation
towards the child and stating the reason for the difference is required (an affidavit is to be
completed by the main member).
• If the child is a student:
- Proof of registration at a recognised tertiary institution; and
- An affidavit from the main member confirming factual dependency on the main member. A
factual dependant is dependent on the main member for family care and support.
• If the child is totally dependent due to mental or physical disability:
- Proof of disability from a medical practitioner (a medical assessment report is to be completed
by a medical practitioner); and
- An affidavit from the main member confirming factual dependency on the main member, and
that the child is not in a state institution.
• If the child is not a student or disabled, an affidavit from the main member confirming factual
dependency on the main member.
• A copy of the child’s ID will be required in all cases.
• An affidavit from the main member confirming factual dependency of any such dependants.
• A copy of the relevant dependant’s ID.
• An affidavit confirming factual dependency of the relevant grandchild on the main member
Note: If the biological parent of the child is also registered as a dependant of the main
member, only an affidavit from the main member, confirming factual dependency of the
grandchild or great grandchild, is required.
• A copy of the grandchild’s ID.
• An affidavit confirming factual dependency of the sibling on the main member (the affidavit to be
completed by the main member).
Note: The sibling of a main member or of a main member’s spouse may be registered as
a dependant.
• A copy of the relevant sibling’s ID.
• An affidavit, confirming factual dependency of niece(s) and/or nephew(s) on the main member
(an affidavit must be completed by the main member and sibling, where applicable).
Note: The children of a sibling of a main member or the main member’s spouse may be
registered as a dependant.
Note: If the parent of the child (the parent being a sibling of the main member) is also
registered as a dependant, only an affidavit from the main member, confirming the factual
dependency of the niece/nephew, is required.
• A copy of the relevant niece’s/nephew’s ID.

ID/Passport no. nnnnnnnnnnnnn Initial 5 of 7

Section E: Affidavit
Regarding dependant

nnnnnnnnn
Membership number nnnnnnnn
D Date
D MM Y Y Y Y
Persal/employee/pension number nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
Please complete this affidavit if:
• The main member needs to declare that dependants are factually dependent on him/her for family care and support. (Section E1)
• The main member has to confirm that a dependant is registered as a student at a recognised tertiary institution. (Section E2)
• The main member has to confirm that a dependant is mentally or physically disabled. (Section E2)
• The parent needs to confirm that the main member is responsible for family care and support. (Section E3)
• The main member wishes to add his/her partner as a dependant. (Section E4)

Section E1: To be completed by main member of GEMS (compulsory)

I, nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
nnnnnnnnnnnnn
ID number , hereby declare the following in respect of the person listed in the table
below. Please select the appropriate block and complete the relevant section in full. Attach a separate sheet if there
is more than one dependant.
I wish to add him/her as my dependant on my membership of GEMS, as he/she is factually dependent on me for family care and
support. He/she is not self-sufficient.

Full first name Relationship

Surname Income of dependant
ID number
Extent of financial
dependency on member
Personal circumstances
of dependant

He/she is under the age of 28 years and is a student and I have included proof of registration at a recognised tertiary institution.

Full first name Relationship

Surname Income of dependant
ID number
Extent of financial
dependency on member
Personal circumstances
of dependant

He/she is mentally or physically disabled and I have included the doctor’s report.

Full first name Relationship

Surname Income of dependant
ID number
Extent of financial
dependency on member
Personal circumstances
of dependant

I wish to add my partner as a dependant on my membership of GEMS.

Full first name Relationship

Surname Income of dependant
ID number
Extent of financial
dependency on member
Personal circumstances
of dependant

ID/Passport no. nnnnnnnnnnnnn Initial 6 of 7

 I am receiving a medical subsidy from my employer in respect of a person.

Full first name Relationship

Surname Income of dependant
ID number
Extent of financial
dependency on member
Personal circumstances
of dependant

Section E2: To be completed by main member of student/disabled person

I,
nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
ID number nnnnnnnnnnnnn
hereby declare that I am the parent of the person in the table and that
____________________________________________ (insert name of main member) is factually and otherwise
responsible for him/her and wants to add him/her as a dependant on my membership of GEMS.

Section E3: To be completed by the parent of dependant when adding a child dependant

nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
I,
ID number nnnnnnnnnnnnn
hereby declare that I am the parent of the person in the table and that
____________________________________________ (insert name of main member) is factually and otherwise
responsible for him/her and wants to add him/her as a dependant on my membership of GEMS.

Section E4: To be completed by the partner if main member is adding a partner as a dependant
I,
nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnn
ID number nnnnnnnnnnnnn
hereby declare that I am the partner of _______________________
_______________________________ (insert name and surname of main member)

Thus declared on this nn day of _______________________ 20 nn at ___________________________

__________________________________________________________________________________________
I know and understand the contents of the declaration. I have no objections to taking the prescribed Oath. I consider
the Oath binding on my conscience. So help me God.

Signed:

Main member of GEMS _________________________________________________ nnnnnnnn

Date D D M M Y Y Y Y

Partner ______________________________________________________________ Date nnnnnnnn

D D MM Y Y Y Y
Parent ______________________________________________________________ Date nnnnnnnn
D D MM Y Y Y Y

The above-mentioned statement was made by the deponent and the deponent
knows and understands the contents of the statement. The statement was
sworn by the deponent and his/her signature placed thereon in my presence STAMP BY COMMISSIONER
on this day ________________________ of _______________________ OF OATHS
in _________________________

Signature of Commissioner of Oaths

ID/Passport no. nnnnnnnnnnnnn Initial 7 of 7