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Resolution Holdings

Healthcard Application Form

Prescribing a better way to take control of your medical expenses

For Office use only
Healthcard Number Membership Number
Membership Type    
*Group Number *Group Name

A. Personal Details
*Surname *Title
Maiden Name *Initials
*First Names (in full) Gender
*I.D Number Marital Status
Date of Birth Name of Spouse
Nationality No. of Dependants
Employer Name Occupation

B. Contact Details
Telephone (H) *Cellphone
Telephone (W) Fax
E-mail Address
*Physical Address *Postal Address
City City
Code Code

C. Secondary Card Holder(s) Details (Submit Secondary applicant)s) Identity document)
Surname Title
Maiden Name Initials
First Name (in Full) Gender
I.D. Number Date of Birth
Relationship to Account Holder
       
Surname Title
Maiden Name Initials
First Name (in Full) Gender
I.D. Number Date of Birth
Relationship to Account Holder

D. Contribution Collection Details
Contribution Type
*Name of Bank *Branch Name
*Account type *Branch Code
*Name of Account Holder
*Account Number    
*Amount to be Debited R
Date of Ist Debit Order  
I understand that the withdrawals hereby authorised will be processed by computer through a system known as the ACB Magnetic Tape Service / Debit order /
Multidata and I also understand that details of each withdrawal will be printed on my bank statement or on an accompanying voucher.

I agree to pay any bank charges relating to this, ACB Magnetic Tape Service / Debit order / Multidata instruction.

This authority may be cancelled by me giving Healthcard. thirty days notice in writing, sent by prepaid registered post, but I understand that I shall not
be entitled to any refund of amounts which Healthcard has withdrawn while this authority was in force if such amounts were legally owing to
Healthcard. Receipt of this instruction by Healthcard. shall be regarded as receipt thereof by my bank.

I further agree to advise Healthcard. in writing of any changes which may occur.


E. Credit Facility
Do you require a credit facility to fund your Healthcard? Yes No
I, hereby authorise Healthcard to forward my personal details, to the Healthcard nominated Credit Provider partner in terms of applying for a credit facility to fund my Healthcard, and that credit terms and conditions are applicable.

F. Declaration
I, the undersigned applicant, warrant that the contents of this application and any other documents which may be required in support thereof are true, correct and complete, whether recorded in writing by me or by any intermediary on my behalf.
       

G. Intermediary Details
Name of intermediary / Consultant    
Intermediary code Telephone Number
Fax Number E-mail Address
       

Important terms and conditions to take note of

The Healthcard (“the card”) is issued by Mercantile Bank Limited (1965/006706/06) (“us/we”) to the persons whose names appear thereon (“you”) subject to the following
terms and conditions:

1. ISSUING OF THE CARD
1.1 All these terms and conditions (‘this agreement“) shall apply without reservation
when we dispatch the card to you.
1.2 All informational material(s) and user guides accompanying this card form an integral part of this agreement. Please ensure that you familiarize yourself with all these materials and/or documents.
1.3 You must sign the card on its reverse side with a ballpoint pen immediately upon receiving it. The card is valid from the date of issue as indicated on your debit card, until your right to use the card is terminated in terms of clause 7.
1.4 The card is owned by us and will remain our property at all times.

2. USE OF THE CARD
2.1 Only the Cardholder in whose name the card is issued and whose name is embossed on the Card may use the card. Use of your Card by a third party is a criminal offence and will be prosecuted accordingly.
2.2 You may only use the card to pay for services of medical/health service suppliers (Doctors, Pharmacies, Optometrist, etc) where an electronic point of sale terminal is available for electronic approval of transactions.
2.3 You may not make purchases or otherwise use the card for transactions that will exceed
the credit balance on your account, or for anything other than medical/health services.
2.4 You will be liable to us for payments made by us in respect of the use of your card.
2.5 Use of the card is at your own risk and we are not responsible for any loss or theft resulting from the use of the card.
2.6 This card will only be valid in the boundaries of South Africa.
2.7 The card may not be used for any unlawful purpose, including but not limited to, the purchase of goods or services prohibited by any law.
2.8 The card is an electronic debit card which can only be used at an electronic point of sale terminal.
2.9 The card is issued with a PIN number to verify the card owner but has been ATM disabled for cash withdrawals.

3. AUTHORITY TO DEBIT YOUR ACCOUNT
3.1 You hereby authorise us to debit your account with:
3.1.1 any and all payments to medical/health service providers made by you using your card or where we act on any written instruction from you,
3.1.2 our standard service fees (where applicable) as notified to you from time to time, including (without limitation) card issue and replacement fees, cancellation fees, debit order return fees and statement fees,
3.1.3 any and all applicable government levies in respect of the use of the card, and
3.1.4 any costs incurred by us enforcing our rights, pursuant to this agreement.
3.1.5 any cost determined by us from time to time relevant in providing a compulsory lost card protection plan.
3.1.6 Any debit balance relating to returned debit orders, applicable fees and interest pursuant to this agreement.

4. STATEMENTS
4.1 On request, we shall give you statements showing the transactions entered into by use of your card, as well as other applicable transactions in respect of your account.
4.2 If you believe that your statement contains an error(s) you must notify us of the error in writing within 30 (thirty) days of the receipt of the statement, failing which you will have no claim whatsoever in respect of or arising from such error(s).

5. INTEREST
5.1 We may pay you interest, at a rate which will be solely determined by us from time to time, in respect of any daily credit balances in your account. Such interest will be credited to your account on a monthly basis.
5.2 Should your account, for any reason, have a debit balance, you will pay us interest at the maximum rate prescribed by the Usury Act or at a rate determined by us from time to time, in respect of any debit balances on your account. Such interest will accrue on a daily basis from the date of the debit balance upon and including the date on which full repayment is credited to our account, and will be compounded monthly in arrears.

6. AUTHORISED USE
6.1 You are responsible for the safekeeping of your card.
6.2 If your card is lost or stolen, you must immediately notify our nearest branch of such a loss. If such notification is effected verbally, you must confirm in writing within 24 (twenty four) hours of verbal notification. Delay in notifying us of the loss or theft will be deemed to be negligence on your part.
6.3 If your card is lost or stolen and your card is used, you will be responsible for all amounts
debited to your account through the use of the card.
6.4 The card is covered under a lost card protection plan whereby the monthly cost and protection limit is determined by us from time to time.

7. TERMINATION OF CARD FACILITY
7.1 You may terminate your right to use the card on written notice to us only once a zero balance has been achieved. The said notice must be accompanied by the card,
which must be cut into pieces so as to prevent further use.
7.2 We may at any time in our sole and absolute discretion close your account and/or terminate
your rights to use the card. If we close your account and/or terminate your right to use
the card, you must immediately return your card to us as set out in clause 7.1.
7.3 In the event that we close your account and/or terminate your right to use the card we shall be entitled to inform any merchant, credit reference agency or other person thereof.

8. LIABILITY
We shall not be liable for any loss or damage that you may suffer as a result of our provision of incorrect information to any person (including any credit reference agency) if such information was provided in good faith, or as a result of any terminal failure or malfunction beyond our reasonable control as a result of the failure or malfunction of any other device used to make or process transactions with the card.

9. ADDRESSES AND NOTICES
We shall send notices to the postal address or, where applicable, to the physical address
specified on your account application form, which address you have chosen as your domicilium citandi et executandi for all purposes arising from this agreement.

10. GENERAL
10.1 We shall not be liable to you if any medical/health service supplier does not accept the card or
we refuse to authorise any transaction on the card.
10.2 The card is an electronic form of payment and we will not be held liable for any amount claimed by a medical/health service supplier, or on your behalf should the medical/health service provider not accept this form of payment.
10.3 You must resolve any dispute you have with any medical/health service suppliers directly with the medical/health service supplier. Such dispute will not affect our rights to receive payment from you.
10.4 If there is a difference between our records and your record, our records will be binding.
10.5 Where a cheque or other negotiable instrument is deposited into and credited to your account, it will be available as cash only after it has been honored and we shall be entitled to debit your account with the amount of that cheque or negotiable instrument if it is dishonored, where we reserve the right to take legal action in recovering used funds against amounts dishonored.
10.6 We may amend this agreement at any time. Publication of such amendments by such means as we may select will constitute valid notice of the amendment to you. Any such amendment(s) will not constitute a negation of this agreement. You may not amend or vary these terms and conditions at all.
10.7 You agree that we may proceed against you in a magistrate’s court having territorial jurisdiction even if the amount of your claim exceeds the value jurisdiction of the court.
10.8 In the event that we take legal action against you to recover any amount due to us in terms of this agreement, you will be liable for our costs (including all legal fees and collection commission) on the scale as between attorney and own client.
10.9 We may allocate any credit balance in any account you have with us to settle or set off any outstanding amount that you may owe us in terms of this agreement. We may realise any security which we held for your indebtedness to us and apply the proceeds thereof to pay any indebtedness in terms of this agreement.
10.10 You agree that you will notify us immediately in the event that you are sequestrated under an administration order or any form of curatorship, or commit any act of insolvency as set out in the Insolvency Act, 1936 (Act No 24 of 1936), as amended.
10.11 A certificate signed by any one of our managers or branch administrators (whose appointment need not be proven) as to the amount of your indebtedness to us (including interest) and that such amount is due and payable shall constitute sufficient proof thereof, unless the contrary is proven in court.
10.12 Any indulgence, extensions of time or concession that we may grant you shall not be
regarded as a waiver of our rights.
10.13 Every provision of this agreement is deemed to be separate and severable, the one from the others. Should any provision be found to be unenforceable for any reason, the remaining provision shall nevertheless continue to be of full force and effect.
10.14 The agreement will be governed by and construed in accordance with the
laws of the Republic of South Africa.
10.15 You consent to us making enquiries concerning your credit history with any credit reference agency and to provide such agencies with both positive and negative information regarding
conduct of your account(s).

Please print this document, sign below with a black pen, attach a copy of your ID and send to:
PO BOX 1555
Fontainbleau
2032
Or submit to any of our regional offices.
Click here for more contact details.
Name: Date:
Identity No. Signature _____________________
       
Verify this form
Type in the code displayed below (Case Sensitive)
   
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© Copyright Resolution 2009 | Access to information | site by STONEWALL +
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