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PART I: MEMBER DETAILS

Surname: ..................................................................................... Other Names:......................................................... NHIF No:...................................................................................... National I.D/Passport/Alien I.D No.:....................... Date of Birth (DD/MM/YYYY):...................................................... Gender (Male/Female): .......................................... Employer/Organized Group Code: ..............................................Sponsor Code: ....................................................... Payroll/Personal No.: ................................................................... Mobile Phone No.: ................................................. Place of Residence (sub county):................................................................................................................................. E-Mail Address:............................................................................................................................................................. Postal Address:............................................................................. Post Code:.............................................................

PART II: SPOUSE DETAILS

Surname: ....................................................................... Other Names: ...................................................................... National I.D./Passport/Alien I.D. No.: ............................ Date of Birth (DD/MM/YYYY):.............................................. Gender (Male/Female):.................................................. Mobile Phone No.: ...............................................................

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PART III: CHILDREN DETAILS AND CHOICE/ CHANGE OF FACILITY

Guidelines:

1. Please attach a copy of Birth Certificate for each child. For children under six (6) months, a birth notification is acceptable.

2. To choose an outpatient medical facility, please refer to the list of our accredited outpatient health facilities available in the N.H.I.F Website and Offices countrywide.

3. To access benefits one MUST be a duly registered member and must have declared their dependant.

4. To choose an OPC Facility, attach a copy of the contributor’s National ID