FLIMAS Membership Application

Membership Application Form

Application Type * Principal Member First Name/s * Principal Member Last Name * Residential Address * Email Address Phone Number * Date of Birth * Gender * Marital Status * Next of Kin ID Number * Occupation Employee Number ID Card Image

Electronic Details

Bank Name Branch Code Account Name Account Number Previous Medical Aid Membership? Select Scheme * Add Dependants

Medical History * HYPERTENSION DIABETES EPILEPSY RENAL LUNG BLOOD DISEASES STROKE CANCER LIVER PSYCHIATRIC NONE OF THE ABOVE OTHER

By submitting, you acknowledge that you have read and understood, and agree to FLIMAS Medical Aid Terms and Conditions