PROGRAM APPLICANT INFORMATION

Please complete the application

All communication is done electronically therefor an email contact address is necessary. If not available, your agent’s email address will be used.

Health Assist

SPOUSE / PARTNER INFORMATION IF APPLICABLE

CHILDREN INFORMATION (18 YEARS AND YOUNGER)

EXTENDED DEPENDANT INFORMATION: ADULT (OLDER THAN 18 YEARS) OR ADDITIONAL CHILDREN

BENEFICIARY (OPTIONAL)

MY DOCTOR’S CONTACT INFORMATION (OPTIONAL)

We undertake to contact your own Doctor and to offer him the opportunity to form part of our doctors’ network. We can’t guarantee that your own doctor will agree to form part of our doctors’ network.

PRODUCT & Membership Options

With my signature I authorise the Company to rectify the membership fee I calculated if incorrect and I accept the membership fee as on the Terms mailed to me with acceptance of Membership.

PAYMENT INFORMATION

Special Note: Debit order Reference on your bank statement will be HERMINIX

Terms & Conditions

A. AUTHORITY: I, the applicant as stated in this application and duly authorised to do so and the undersigned hereby authorise Herminix (Pty) Ltd as Administrator and Beneficiary, and or its collecting agent, currently SoftyComp, to deduct the confirmed amounts in the application from my current bank account as stated above or any other bank account that I may transfer my account to. This signed Authority and Mandate refers to our contract with Herminix for my Health Assist Program membership as dated on the application ("the Agreement"). I/We hereby authorise you to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned bank (or any other bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement, and commencing on the date of this application and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of not less 20 ordinary working days, and sent by prepaid registered post or delivered to your address indicated above. The individual payment instructions so authorised to be issued must be issued and delivered as in the application form ("payment day") of each and every month commencing on the date of deduction as in this application. In the event that the payment day falls on a Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account; monthly; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less than the obligation due; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less than the obligation due. I /We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement or on an accompanying voucher. Such must contain a number; which number must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. This number must be added to this form in section E before the issuing of any payment instruction and communicated to me directly after having been completed by you. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

B. MANDATE: I/We acknowledge that all payment instructions issued by you shall be treated by my/our above-mentioned bank as if the instructions had been issued by me/us personally.

C. CANCELLATION: I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.

D. ASSIGNMENT: I/We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. We acknowledge that you utilise the services of Softy Comp for this collection.

E. THE REFERNCE ON THE BANK STATEMENT WILL BE: HERMINIX.
I hereby agree that I applied for the Health Assist Membership on my own account and free will and that I accept the terms, conditions, limitations and waiting periods. I confirm that I can afford the agreed monthly contribution.

Price Table

    Please download and complete the debit order instruction

    After completion kindly email the document back to us within 24 hours.