Individual Enrollment to Y.E.S. Health Program (Y.E.S.HP)

Y.E.S. HEALTH PROGRAM (Y.E.S.HP)
INDIVIDUAL ENROLLMENT

(For Individual & Family Coverage)
ENROLLMENT DATE:

MonthDayYear
ENROLLEE INFORMATION

SURNAME OR LAST NAMEFIRST NAMEMIDDLE NAME
DATE OF BIRTH
YEAR/MONTH/DAY
Bank Verification Number (BVN)
MARITAL STATUS
GENDER
WhatsApp Phone #
(Include Country Code)
E-mail
example@example.com
RESIDENTIAL ADDRESS
PLAN TYPE
ARE THERE ANY PRE-EXISTING CONDITIONS (COMPULSORY)?
IF YOU ANSWERED "YES" TO PRE-EXISTING CONDITIONS (COMPULSORY), PLEASE USE BLANK SPACE BELOW TO LIST THOSE CONDITIONS:
This section applies to both individuals and Family Members having a pre-existing condition.
Will you be the Responsible Person to contact for payment and/or other information needed?
IN CASE OF AN EMERGENCY:

(Please provide information as indicated)
PRIMARY HOSPITAL
(Provide the Name of Your Primary Hospital Choice)
SECONDARY HOSPITAL
(Provide the Name of Your Secondary Hospital Choice)
IF THERE ARE NO DEPENDENTS, PLEASE SKIP THE NEXT SECTION FOR PROVIDING DEPENDENT INFORMATION AND SUBMIT YOUR ENROLLMENT FORM NOW.
DEPENDENT INFORMATION:

Please provide information on each dependent in the blank space shown to include name, birthdate (month,day, year) relationship) separated by commas. FOR EXAMPLE: Mary Jane Ashton, Born December 12, 1985, Daughter)
DEPENDENT 1:
Dependent Name, Birthdate & Relationship
DEPENDENT 2:
Dependent Name, Birthdate & Relationship
DEPENDENT 3:
Dependent Name, Birthdate & Relationship
DEPENDENT 4:
Dependent Name, Birthdate & Relationship
DEPENDENT 5:
Dependent Name, Birthdate & Relationship
Thank you and welcome to Y.E.S. HEALTH PROGRAM (Y.E.S.HP). A representative will be contacting you to complete your enrollment process.
Should be Empty:

Y.E.S. HEALTH PROGRAM (Y.E.S.HP)

INDIVIDUAL ENROLLMENT

IN CASE OF AN EMERGENCY:

DEPENDENT INFORMATION: