Principal Subscriber Enrolment Company/Employer Name *Your Office/Station/Branch *Surname *First Name *Other NameDate of Birth *Ghana Card NumberPhone Number(s) *Phone Number (2)Email Address *Town/Suburb of Residence Preferred Service Provider * Benefit Plan * -- Select Plan -- BronzeSilverGoldPlatinumPlatinum Star Number of Dependants Pre-Existing Conditions (tick as applicable) 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 Cancer (Specify) * History of Surgery * Other Known pre-existing Medical Condition Attestation * Signature Dependants Add Dependant Submit Enrolment Thank you! Your enrolment has been submitted successfully.A confirmation email has been sent to your address. OK DependantRemove Relationship with Principal Subscriber * Surname * First Name * Other Name Date of Birth * Ghana Card Number Phone Number(s) Phone Number (2) Email Address Town/Suburb of Residence Preferred Service Provider * Benefit Plan * -- Select Plan -- BronzeSilverGoldPlatinumPlatinum Star History of Cancer (Specify) * Pre-Existing Conditions 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 Attestation * Signature
