Application to Open a Savings / Investment Account

If you are a healthcare professional, healthcare worker or medical industry stakeholder and comply with the minimum requirements, you can either complete the account opening form below (online application process) or you can follow our manual application process by downloading our Open a Savings/Investment Account Form using the link provided.

Open a Savings Account MediCoop terms & conditions Accident cover terms & conditions

Application Type

* South African Citizen / Entity

* Apply as Individual or Business

* Business Type

Individual or Company Information

* ID Number

Business Reg Number

Business Name

* Title

* Initials

* Full Name(s)

* Surname

Nickname

* Marital Status

Spouse Name

Spouse ID Number

Spouse Contact Number

* Cellphone

Telephone

* Email Address

* Gender

* Race

Date Of Birth

Physical Address

* Line 1

Line 2

* Suburb

* City/Town

* Postal Code

Postal Address

* Line 1

Line 2

* Suburb

* City/Town

* Postal Code

Work Address

Line 1

Line 2

Suburb

City/Town

Postal Code

HPCSA Number

Practice Number

Other Professional Body or Association Membership Number

Specify Professional Body or Association

Employer / Place of Work

Employer Contact Number

Primary Account Information

Name Of Bank

Branch Name

Branch Code

Account Number

Account Type

Date Opened

Business Information

* Nature of Business

Date Established

Auditor

Auditor Contact Number

Business Short-Term Insurer

Business Short-Term Insurer Contact Number

Medical Malpractice Insurer

Medical Malpractice Insurer Contact Number

Company / Business Shareholding

Shareholder 1

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Shareholder 2

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Shareholder 3

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Shareholder 4

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Shareholder 5

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Type of Account

* Account Type

* Account Held By

Investment Period

Amount to be Invested

Other Investment Requirements

Where did you hear about us?

* Discovery Media

Source

Consent

* I/We, the applicant(s) and the signatory(ies) hereof in my/our personal capacities, hereby:

I/we declare that to the best of my/our knowledge and belief, the particulars set out in this application are true and correct, and that no additional or relevant information was withheld.
I/we give consent to the process of personal information and allow SA Primary Medical Financial Co-Operative Limited ("MediCoop CFI") to communicate with/contact me regarding membership information, the affairs of MediCoop CFI, its products and services available to members in terms of the Protection of Personal Information Act 4 of 2013. I/we agree that MediCoop CFI can use your photograph(s) to check your identity and FICA information from the Department of Home Affairs (DHA) and at any other party to confirm any aspect or details of this application. I/we agree to the terms and conditions.

Type the code from the image