Dependent Registration

Dependant Membership Form

Passport Picture *

Maximum file size: 2.1MB

First Name *

Last Name *

Other Names

Date of Birth *

Sex *

Male

Female

Tel No.

Are you registered under NHIS? *

Yes

If yes, NHIS No.

Principal Member’s Name *

Principal Member’s Company *

Relationship to Principal Member *

Medical History (Kindly select as many as apply to you) *

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 *

(For Children, Principal Member should sign on their behalf). Please type your name.

If you are human, leave this field blank.

Dependent Registration

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