NHIF 2 (Revised 2006)

NATIONAL HOSPITAL INSURANCE FUND

P.O. Box 30443, NAIROBI
Website: www.nhif.or.ke Email: info@nhif.or.ke

REGISTRATION FORM
PARTICULARS OF CONTRIBUTORS, SPOUSE AND CHILDREN

Tick where applicable Employed S/Employed Organised groups

PART I: CONTRIBUTORS PARTICULARS

Surname:........................................................... Other Names...............................................................................
NHIF Card No:................................................... ID. No/PP No/COR No ................................................................
Date Of Birth:..................................................... Sex (M/F)....................................................................................
Employers/Organised Group Name:........................................................................................................................
Employer/ Organised Group Code .........................................................................................................................
Date Of Appointment ........................................ Employment No ..........................................................................

PART II: SPOUSE PARTICULARS

Surname:........................................................... Other Names...............................................................................
ID. No/PP No/COR No....................................... Date Of Birth: ..............................................................................
NHIF Card No:................................................... Sex (M/F)....................................................................................
Employers/Organised Group Name:........................................................................................................................
Employer/ Organised Group Code .........................................................................................................................
(Please attach photocopies of National ID Cards for both contributor and spouse)

PART III: CHILDRENS PARTICULARS

(Only to be provided by one parent where both are contributors)

For Official
School/College
Name of Child Date of Birth Use Only
(being Attended)
(dependant No)
Sex
Date Month Year
F/m
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
(Please attach photocopies of any of the following: birth certificate, birth notification, baptismal card or
immunization card)

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 NHIF 2 (Revised 2006)
EMPLOYERS AUTHORISED OFFICIAL

Name _________________________________ Signature __________________ Date __________________

Official Rubber Stamp ________________________________________________________________________

PART IV: (To be completed by SELF EMPLOYED person and those engaged
in the INFORMAL SECTOR)

a) RESIDENTIAL DETAILS

Postal Address .....................................................................................................................................................

URBAN AREA RURAL AREA

ESTATE ..................................................................... DISTRICT .....................................................................

PLOT........................................................................... DIVISION .....................................................................

TOWN STREET/ROAD................................................ SUBLOCATION ............................................................

VILLAGE.......................................................................

b) Occupation (e.g Farming) ...................................................................................................................................

c) Name Of Organised Group ............................................................................. Code .........................................
d) Name Under Which Your Business Operates ......................................................................................................
e) Were You A Contributor To The Fund Before? (Y/N) ...............
If yes, state name of last employer/Your previous no ..........................................................................................

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 NHIF 2 (Revised 2006)
PART V: PHOTOGRAPHS

Please attach coloured passport photographs for each of the persons named in Part I, II, III Indicate name of the
person and the ID number at the back of the passport photograph.

CONTRIBUTOR SPOUSE 1st CHILD

Contributor’s Name: Spouse’s Name: Child’s Name:

................................................................. ................................................................. .................................................................

................................................................. ................................................................. .................................................................

................................................................. ................................................................. .................................................................

Card No: ............................................... Card No: ............................................... Dependant No: ...................................

2nd CHILD 3rd CHILD 4th CHILD

Child’s Name: Child’s Name: Child’s Name:

................................................................. ................................................................. .................................................................

................................................................. ................................................................. .................................................................

................................................................. ................................................................. .................................................................

Dependant No: ................................... Dependant No: ................................... Dependant No: ...................................

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 NHIF 2 (Revised 2006)

5th CHILD 6th CHILD 7th CHILD

Child’s Name: Child’s Name: Child’s Name:

................................................................. ................................................................. .................................................................

................................................................. ................................................................. .................................................................

................................................................. ................................................................. .................................................................

Dependant No: ................................... Dependant No: ................................... Dependant No: ...................................

8th CHILD 9th CHILD 10th CHILD

Child’s Name: Child’s Name: Child’s Name:

................................................................. ................................................................. .................................................................

................................................................. ................................................................. .................................................................

................................................................. ................................................................. .................................................................

Dependant No: ................................... Dependant No: ................................... Dependant No: ...................................

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 NHIF 2 (Revised 2006)

PART VI: CERTIFICATION: I certify that the information given is correct to the best of my knowledge

Name _________________________________ Signature ___________________ Date _________________

FOR OFFICIAL USE ONLY

a) Approving Officer _______________________________ Sign ____________________ Date ___________

b) Data Entry Officer _______________________________ Sign ____________________ Date ___________

c) Validation Officer ________________________________ Sign ____________________ Date ___________

d) System File Officer ______________________________ Sign ____________________ Date ___________

e) Scanning Officer ________________________________ Sign ____________________ Date ___________

f) Photo process Officer _____________________________ Sign ____________________ Date ___________

g) P/Card Printing Officer ___________________________ Sign ____________________ Date ___________