AXA MANSARD HMO ENROLMENT FORM PERSONAL DETAILS Question Title Staff ID (without the year e.g. 1234) Question Title Last Name (Surname) Question Title First Name Question Title Middle Name Question Title Grade OO1 OO2 OO3 OO4 OO5 OO6 ET ABO BO SBO AM DM MGR Question Title Official Email (e.g f.l@gtbank.com) Question Title Personal Email Question Title Mobile Number (e.g 080XXXXXXXX) Question Title Location Abia Abuja Adamawa Anambra Akwa Ibom Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Enugu Edo Ekiti Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara ______________________________________________________________________________________________________________ DETAILS OF DEPENDENTS Kindly note the age clause for enrolment (Parent not older than 65 years and children not older than 25 years) Question Title Number Of Dependents (maximum of 5) 0 1 2 3 4 5 Question Title Surname Question Title First Name Question Title Middle Name Question Title Relationship Father Mother Son Daughter Husband Wife Question Title Surname Question Title First Name Question Title Middle Name Question Title Relationship Father Mother Son Daughter Husband Wife Question Title Surname Question Title First Name Question Title Middle Name Question Title Relationship Father Mother Son Daughter Husband Wife Question Title Surname Question Title First Name Question Title Middle Name Question Title Relationship Father Mother Son Daughter Husband Wife Question Title Surname Question Title First Name Question Title Middle Name Question Title Relationship Father Mother Son Daughter Husband Wife ______________________________________________________________________________________________________________ Question Title Mansard HMO Premium Principal only - N110,000 Principal + 1 Dependant (2 Lives) - N220,000 Principal + 2 Dependants (3 Lives) - N330,000 Principal + 3 Dependants (4 Lives) - N440,000 Principal + 4 Dependants (5 Lives) - N550,000 Principal + 5 Dependants (6 Lives) - N660,000 Family (4 Lives to a max of 6 lives) - Nuclear family - N400,000 Family (4 Lives to a max of 6 lives) - One Enrolee's Parent Inclusive - N510,000 Family (4 Lives to a max of 6 lives) - Both Enrolee's Parents Inclusive - N620,000 Question Title NOTE: You will be redirected to the AXA-Mansard Health page to complete your registration. Please note that only then will your enrollment for 2018 be complete. Kindly tick the box below to confirm that you understand that your registration MUST be completed with AXA-Mansard Health for the 2018 plan to be active. I Agree Done
