Mediplan Healthcare Limited: Mediplan Online Platform

Fieldset

ENROLEE CATEGORY *
CORPORATEPRIVATE
PLAN TYPE *
LAST NAME *
FIRST NAME *
MIDDLE NAME *
DATE OF BIRTH (in the format DD/MM/YYYY) *
GENDER
MaleFemale
STATE OF ORIGIN *
MARITAL STATUS
SingleMarried
NAME OF EMPLOYER *
CITY *
ADDRESS OF EMPLOYER *
STATE
RESIDENTIAL ADDRESS *
MOBILE *
HOMEPHONE
EMAIL ADDRESS
PLEASE UPLOAD YOUR PHOTOGRAPH (The file size should be smaller than 2MB and the photo size should be smaller than 3072 X 2304. The system processes only .jpg or .jpeg files)
SPOUSE FIRST NAME
SPOUSE MIDDLE NAME
SPOUSE DATE OF BIRTH
SPOUSE GENDER
UPLOAD PHOTOGRAPH OF SPOUSE (The file size should be smaller than 2MB and the photo size should be smaller than 3072 X 2304. The system processes only .jpg or .jpeg files)
FIRST CHILD FIRSTNAME
FIRST CHILD MIDDLENAME
FIRST CHILD DATE OF BIRTH
FIRST CHILD GENDER
UPLOAD PHOTOGRAPH OF FIRST CHILD (The file size should be smaller than 2MB and the photo size should be smaller than 3072 X 2304. The system processes only .jpg or .jpeg files)
SECOND CHILD FIRSTNAME
SECOND CHILD DATE OF BIRTH
SECOND CHILD MIDDLENAME
SECOND CHILD GENDER
UPLOAD PHOTOGRAPH OF SECOND CHILD (The file size should be smaller than 2MB and the photo size should be smaller than 3072 X 2304. The system processes only .jpg or .jpeg files)
THIRD CHILD FIRSTNAME
THIRD CHILD MIDDLENAME
THIRD CHILD DATE OF BIRTH
THIRD CHILD GENDER
UPLOAD PHOTOGRAPH OF THIRD CHILD (The file size should be smaller than 2MB and the photo size should be smaller than 3072 X 2304. The system processes only .jpg or .jpeg files)
FOURTH CHILD FIRSTNAME
FOURTH CHILD MIDDLENAME
FOURTH CHILD DATE OF BIRTH
FOURTH CHILD GENDER
UPLOAD PHOTOGRAPH OF FOURTH CHILD (The file size should be smaller than 2MB and the photo size should be smaller than 3072 X 2304. The system processes only .jpg or .jpeg files)
CHOICE OF HOSPITAL for PRINCIPAL *
CHOICE OF HOSPITAL for SPOUSE
CHOICE OF HOSPITAL for CHILD 1
CHOICE OF HOSPITAL for CHILD 3
CHOICE OF HOSPITAL for CHILD 4
BY CLICKING THE “SUBMIT” BUTTON AT THE END OF THE FORM YOU ARE CREATING AN ELECTRONIC SIGNATURE. THE SUBMISSION OF AN APPLICATION CONTAINING ANY FALSE OR MISLEADING STATEMENTS MAY RESULT IN DENIAL OF YOUR MEDICAL COVER. *
I AGREE TO THE ABOVE TERMS

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