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SICK/ACCIDENT/MATERNITY CLAIM FORM
Phone: 010 261 5392
Email: safclaims@ms.org.za
RMILogo
OSAFC-2512082201235972
Claim Type * MIBCO Council Number
Member Full Name* Member Surname*
Member Identity or Passport Number* Member Contact Number*
Details Of The Employer
Employer Number
Employer Name*
Period Of Absence Due To Sickness/Accident/Maternity
Absence Date From* Absence Date To*
The member is employed and remunerated as follows:
Working Days Per Week* Member Income* Payment Interval (Weekly/Monthly)*
Refund claim back to (Employer / Member)?*
Èmployer Member
Banking details of payee (Employer / Member):
Name Of Account Holder*
Name Of Bank* Branch Code*
Account Number*

* Please note that banking details will be verified against member ID Number or employer registration number

NOTE: BANK STATEMENT OR PRINTOUT FROM THE BANK MUST BE ATTACHED.**

We, the Employer and Employee, certify that the information as given above is correct:

Company Stamp

Signature:                                                                                       Date:                                                          Member's Signature:
MEDICAL OFFICER'S CERTIFICATE
 The Medical Certificate must clearly state the name of the patient and the date unfit for work and the nature of illness, and must be attached to the back of this application form. If the illness is an injury due to an accident please state below the cause and the place of the accident.



A medical certificate is not required in the event that a Member is absent from work for one day only, and such day is not a Monday, Friday or any other day preceding or following a normal day off.

The sick accident maternity agreement requires us to process your personal information. We consider the grounds listed below to be relevant:
1. That by completing these claim forms (Sick and accident Claim Form and maternity claim form), you give consent to us to use your personal information in a certain way.
2. Where necessary so that we can comply with the legal Obligation to which we are subject (for example where we are obligated to share your personal information with the regulatory bodies which govern our work and services including the Funds I.E Motor Industry Retirement Funds MIRF, that we are contracted to, which extend to MIFA as an administrator governing the investment of provident Fund monies that we collect monthly on behalf of MIRF),the FSCA, LABOUR DEPARTMENT, and MIBCO's stake holders.
3. Where necessary for the performance of a contact to which we are a party, or to take steps at your request via enforcement processes. Or to take steps where there are no-compliance.
4. Where it is your or someone else's vital interest (in case of emergency and your Family member as authorised in writing, needs to act on your behalf).
This is to allow us to comply with POPI act 4. Of 2013, in terms of handling of personal information.
We therefore consider your privacy very important and as such please visit our website at www.mibco.org.za for further details, where you can view our Privacy Policy on how we protect and process your data.




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