Client Enrolment Form Company Code Unique Company Code * Principal Subscriber Enrolment Company/Employer Name * Your Official Position/Role Surname * First Name * Other Name(s) Gender * Select gender Male Female Date of Birth * Ghana Card Number * Phone 1 * Phone 2 Email Address * Town / District Preferred Service Provider Benefit Plan Select Benefit Type Bronze Silver Gold Platinum Platinum Star Orange Signature Pre-Existing Conditions (tick as applicable) None Pregnant Heart Disease Pulmonary Disease Kidney Disease History of Stroke Bronchitis Diabetes History of Epilepsy Autoimmune Disorders Hypertension Parkinson's Disease HIV/AIDS Asthma Depression Tuberculosis Arthritis Bipolar Disorder Mental Health Conditions History of Surgery Other Known Pre-existing Medical Condition Upload Document (Passport Picture, etc.) I attest that the information I have provided above is true and accurate. Signature (typed name) * Dependants + Add Dependant