Enrollment form- AMMBAN MONTHLY PLAN - NEM-HEALTH

Enrollment platform- AMMBAN MONTHLY PLANS

REGISTER AS A PRINCIPAL
REGISTER A DEPENDENT

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TITLE*

MR

MR
MRS
MISS

FIRST NAME*

LAST NAME*

OTHER NAMES

DATE OF BIRTH*

GENDER*

MALE

FEMALE

PHONE NUMBER*

HOUSE ADDRESS*

0 / 0

Email*

STATE*

LOCAL GOVERNMENT*

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NAME OF PRINCIPAL*

STATUS OF DEPENDENT*

SPOUSE

SPOUSE
CHILD 1
CHILD 2
CHILD 3
CHILD 4

TITLE*

MR

MR
MRS
MISS

FIRST NAME*

LAST NAME*

OTHER NAMES

DATE OF BIRTH*

GENDER*

MALE

FEMALE

PHONE NUMBER (PRINCIPALS)*

HOUSE ADDRESS*

0 / 0

Email*

STATE*

LOCAL GOVERNMENT*

COVERAGE CLASS

YOU ALONE YOU AND YOUR FAMILY

TITLE

LAST NAME

FIRST NAME

OTHER NAME

DATE OF BIRTH

GENDER

MARITAL STATUS

MOBILE PHONE

HOME ADDRESS

EMAIL

STATE

LGA

PREFERRED HOSPITAL

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