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Membership Application Form

Complete the details below to apply for cover. Fields marked with * are required.

Personal Details

Application Type:

Self-Payer

Company

Principal Member First Name/s *

Principal Member Last Name *

Postal Address

Residential Address *

Email Address

Phone Number *

Country code

Phone number

Date of Birth *

Gender *

Select Gender

Marital Status *

Select Marital Status

Next of Kin

Weight(Kgs)

Height(cm)

ID Number *

Occupation

Employee Number

ID Card Image ID Card image is optional but recommended for faster processing

Electronic Details

Bank Name

Branch Code

Account Name

Account Number

Have you have been a member of any Medical Aid in the past?

Yes

Plan Applied For

Select Plan *

OAK PLAN (USD)$238

OAK PLAN (ZWG)6,262 ZWG

TEAK PLAN (USD)$159

TEAK PLAN (ZWG)5,197 ZWG

MUKWA PLAN (USD)$125

MUKWA PLAN (ZWG)3,369 ZWG

MUKWA LITE PLAN (USD)$76

MUKWA LITE PLAN (ZWG)1,914 ZWG

PINE PLAN (USD)$28

PINE PLAN (ZWG)731 ZWG

MEDACCESS (USD)$5

MEDACCESS (ZWG)196 ZWG

HEALTH4U (USD) $5

Dependencies

Medical History *

To be completed by all members

Have you/your dependants suffered/ or is suffering from any of the following? (Required)

HYPETENSION

EPILEPSY

RENAL

LUNG

BLOOD DISEASES

STROKE

CANCER

LIVER

PSYCHATRIC

NONE OF THE ABOVE

OTHER

Terms & Conditions *

By submitting, you acknowledge that you have read and understood, and agree to Bonvie Medical Aid Terms and Conditions