GROUP

FORM
SECTION A: PRINCIPAL MEMBER DETAILS

GROUP/COMPANY NAME: POLICY NUMBER:

FULL NAME OF MEMBER: DATE OF BIRTH:

EMPLOYEE NUMBER: SEX:

DESIGNATION: ID NUMBER:

PLAN TYPE: CELL NUMBER:

MARITAL STATUS: EFFECTIVE DATE:

E-MAIL ADDRESS: PREMIUM P/MTH:

PHYSICAL ADDRESS:

SECTION B: MODE OF PAYMENT METHOD/BANK DETAILS

CASH: Tick If DEBIT ORDER: Tick If STOP ORDER: Enter Company Name If Applicable
Applicable Applicable

SECTION C: PLEASE GIVE INFORMATION OF YOUR FAMILY AND OTHER DEPENDANTS COVERED:
NAME DATE OF BIRTH ID NUMBER RELATIONSHIP

SECTION D: EMPLOYEE DECLARATION

I DECLARE TO THE BEST OF MY KNOWLEDGE THAT, THE PARTICULARS GIVEN ABOVE ARE TRUE AND CORRECT. I AM FULLY AWARE
THAT ONLY THOSE REGISTERED ABOVE WILL GET COVER.
PROPOSER SIGNATURE: _____________________________ DATE: __________________