1.  Employer Number/s:
2.  Employer Name/s:
3.  Intermediary Number:
4.  Intermediary Name:

I/We the abovenamed employer:

• Membership and Group Maintenance
• Registration/Deletion of employees
• Interactive reconcilliations

3.  Agree that this authorisation shall remain in force until notice in writing from 
     , terminating the authorisation is received by 
    Sovereign Health, provided that any such notice shall not affect the completion by
    MMSA of any transactions or administration already initiated pursuant to
    this authorisation prior to termination.

4.  Agree that the appointment of is at my/our sole risk  

5.  Acknowledge that MMSA accepts no liability for any loss, damage
     (whether indirect, special or consequential) or expense of anynature whatsoever
     which may be suffered by me/us arising out of or in connection with this authority,
     in particular, but without limitation, as a result of incorrect instructions given by
    

I/We acknowledge that I/we have read and understood the contents of this application form and agree to be bound by the terms and conditions contained herein.

        Signature(s)                                             (Employer)

        Date                                                      

Please send a certified copy of your ID with this form.