Principal Member Registration

AA Principal Member Registration Form

Passport Picture *

Maximum file size: 2.1MB

Title *

First Name *

Surname *

Other Names

Date of Birth *

Sex

Female

Male

Marital Status *

Tel No.

Company Name *

Postal Address

City

State/Province

Zip/Postal

Country

Are you registered under NHIS?

Yes

If yes, NHIS No.

Kindly select as many as apply to you – press and hold ctrl key to select multiple

Disclaimer

Declaration

By submitting this form, you confirm to the best of your knowledge and belief that the information you have provided is accurate and truthful. The information you have provided will be processed according to our privacy policy. Any false information provided on this form will result in the refusal of your application or termination of your membership and any payments made on your behalf shall be demanded.
I confirm that I have read and understood the terms above.

Sign *

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Principal Member Registration

Our Services

Corporate Health Insurance

Third-Party Administration

Ace Family Health Plan

Ace UniCare Plan

Address Details

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