envelope[email protected]phone+2348037147245

Complete and submit this application / risk evaluation form to determine the subscription plan which is applicable to you.

SURNAME:*
OTHER NAMES:*
DATE OF BIRTH:*
 / 
 / 
STATE OF ORIGIN:*
Local Government Area:*
L.G.A. ADDRESS:*
MARITAL STATUS:*
NAME OF SPOUSE:*
NAME & ADDRESS OF EMPLOYER OF SPOUSE:*
SPOUSE’S OFFICE/ GSM NO:*
-
IS YOUR SPOUSE YOUR NEXT OF KIN?:*
NAME OF YOUR NEXT OF KIN:*
NEXT OF KIN OFFICE / GSM NO:*
-
NAME/ADDRESS OF EMPLOYER OF NEXT OF KIN:*
RESIDENTIAL ADDRESS IN FULL:*
NEAREST B/STOP:*
RESIDENTIAL TEL NO:*
-
EMAIL:*
UPLOAD EVIDENCE OF RESIDENCE / BUSINESS ADDRESS (E.g. NEPA receipts, Rent Agreement, Water Corporation bills, Phone bills etc):*
POSITION / DESIGNATION:*
SPECIALTY:*
YEARS OF PRACTICE AS SPECIALIST (in number):*
YEARS LEFT BEFORE RETIREMENT (in number):*
FORM OF EMPLOYMENT TO BE INDEMNIFIED:*
ANY PRACTICE ISSUES RELATING TO LITIGATION IN THE PAST?:*
INCORPORATION CERTIFICATE / BUSINESS NAME REG. OF OWNED PRACTICE FACILITY(upload copy if applicable):
ANY MEDICAL CONDITION:*
STATE TYPE OF MEDICAL CONDITION:*
INSURED AMOUNT (Number):*
DETAILS OF BANK ACCOUNTS
BANK NAME:*
BRANCH:*
ACCOUNT NUMBER:*
NAME OF EACH FACILITY, ADDRESS, FULL-TIME (FT) OR PART-TIME (PT), CONTACT PHONE AND EMAIL*

IMPORTANT INFORMATION

Please note: All the information contained in this application form will be forwarded to our insurers.


Kindly confirm that this is acceptable to you:*
Recaptcha Word Verification:
Colors Template Settings
Select color sample for all params
blueblue-skygreenorangepinkpurple
Select Layout