Please wait, Verifying ID...
Loading...
EMPLE HEALTH INSURANCE ONBOARDING FORM
Principal Member
PRINCIPAL MEMBER
Select Plan :
Champagne
Burgundy
Turquoise
Orange
Title :
Mr
Mrs
Dr
Miss
Surname :
Middle Name :
Registered First Name :
Marital Status :
Single
Married
Divorced
DOB :
Gender :
Male
Female
Phone Number :
Email Address: :
ID Type :
Ghana Card
Voter's ID
National ID
ID Number :
Upload Passport Picture:
Spouse/Partner Details
Title :
Mr
Mrs
Dr
Miss
Surname :
Gender :
Male
Female
Middle Name :
Registered First Name :
DOB :
Weight :
Cell Phone :
Upload Passport Picture:
Dependants
Add Dependants
MEDICAL HISTORY
Do you any any medical history to declare?
No
Yes
Please State :
Declaration
Declaration and Agreement
(a) Should I be enrolled as a member of The Scheme, I will subject myself to the rules of The Scheme. The information herein is completed true to the best of my knowledge and conviction. No relevant information has been omitted. If after my admission to The Scheme, it is found that my statement or information furnished by me was knowingly and willfully inadequate or untrue, I agree to refund in full to The Scheme all payments which The Scheme have made on my behalf and to relinquish any claim to any benefits on the part of The Scheme.
(B) Should there by any deterioration or change in my state of health or in that of any of my dependants before the date or event to be set by The Scheme for the commencement of membership or the date of acceptance of this application by The Scheme; or the date of receipt of the first contribution, (whichever date is the latest), The Scheme will be entitled to reconsider the application and propose new terms of admission or declare the membership null and void.
(C) Any monies paid to The Scheme in terms of this membership, before The Scheme is informed of the change, shall be forfeited and benefits paid by The Scheme, shall immediately be refunded to The Scheme.
(d) I am bound now, and in the future, if we (myself and my dependants) are accepted as members, to give The Scheme all such information and evidence to The Scheme as they require from time to time. I authorise the attending medical practitioner or any other provider, to provide The Scheme with such information as it may require, hereby waiving the provisions of any law or regulation restricting the giving of such information.
(e) I undertake to pay any other amount due to The Scheme, on default. I hereby authorise my employer to deduct the due amount from my salary or any other monies due by me.
(g) I agree to call The Scheme client services with regards to any queries and pre-authorise any treatment as required by The Scheme
Sigature
Clear
Review
