top of page

INFORMAL PLAN ENROLLMENT FORM

PERSONAL INFORMATION

Marital Satus
Sex
Male
Female
Birthday
Day
Month
Year
Religion
Christianity
Islam
Traditional Religion
Judaism
Hinduism
Buddhism
Other
Occupation
Health Plan

Contact Information

L.G.A of Residence

Medical Information

Genotype
Blood Group
Any Previous Health Conditions?
Yes
No
EDOHIS ID CARD
Physcial Card
Virtual Card
Amount Paying
NGN

Please make direct payment to the following account:

Account Name: EDO STATE – HIS INFORMAL

Account Number: 1222577132

Bank: Zenith Ban

Kindly upload receipt

Edo State Health Insurance Scheme

bottom of page