PHB HEALTHCARE LIMITED

Enrolment Form

(To be completed by every employee/member)

1.

Personal Data:
Surname: ---------------------------- Other Names:------------------------- Middle Name: ------------------------Occupation: ------------------------- Marital Status: ----------------------- Tel. No.----------------------------------E-mail: -------------------------------- Genotype: ---------------------------- Blood Group: --------------------------Date of Birth: -------- ----------- Sex: ------------ Residential Address ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Plan Selection:
Standard
Top-Up
Special
Special Plus
Elite

2.

Employers Data:
Name of Company: ---------------------------------------------------------------------------------------------------------Address: ---------------------------------------------------------------------------------------------------------- -------------

3.

Choice of Hospital:
Name of Hospital: ---------------------------------------------------------------------------------------------------------Address: ----------------------------------------------------------------------------------------------------------------------

4.
Dependants:
NB: Any undeclared pre-existing health condition at the point of registration will not be taken care of.
Dependants Name
Date of Birth
Name of
Sex Medical Conditions
Hospital
Spouse
Child 1
Child 2
Child 3
Child 4

Please write the name of each member on the reverse side of the photograph.
Employee/Members Signature ---------------------------------------------------

Date: --------------------------------------

FOR OFFICIAL USE ONLY:

Received By: -------------------------------------------------

Date: ---------------------------------------

Approved By: ------------------------------------------------

Date: ---------------------------------------

BANK PHB BUILDING, (2ND FLOOR) 1, KEFFI STR., S/W, IKOYI, LAGOS. TEL: 01-8134112, 7450657

PDF created with pdfFactory Pro trial version www.pdffactory.com