INFORMAL PLAN ENROLLMENT FORM

Passport upload

PERSONAL INFORMATION

First name

Last name

Marital Satus*

Sex

Male

Female

Birthday*

Day

Month

Year

Religion*

Christianity

Islam

Traditional Religion

Judaism

Hinduism

Buddhism

Other

Occupation*

Health Plan*

NIN

Contact Information

Address*

L.G.A of Residence*

Ward

Phone

E-mail

Medical Information

Genotype

Blood Group

Any Previous Health Conditions?

Yes

No

If yes, state condition(s)

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

Upload Recipet

edo state health insurance scheme

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