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THE FAMILY INDEMNITY PLAN

MEMBER ENROLLMENT FORM

Have you previously had a Family Indemnity Plan? *       Yes No

Are you or any person(s) who will be listed below presently covered under another Family Indemnity Plan? *       Yes No

Open Enrolment Period Applicable? *       Yes No From To

Organisation: *


Membership Number: *


Telephone No: *


Street:


City:


Country:

Please complete a Designation of Beneficiary Form if you are the only person on this form or if all insurers are minors.

NAME DATE OF BIRTH SEX RELATIONSHIP TO MEMBER
1 First Name:
Last Name:
DOB: M
F
2 First Name:
Last Name:
DOB: M
F
3 First Name:
Last Name:
DOB: M
F
4 First Name:
Last Name:
DOB: M
F
5 First Name:
Last Name:
DOB: M
F
6 First Name:
Last Name:
DOB: M
F

Plan Selected:

Benefit Amount:

I acknowledge that I have read and understood the Terms and Conditions of Service

Please include the premium payment along with this Enrolment Form

Amt. Paid:

Date Paid:



(Signature of Member)

(Signature of Authorized Organisation Officer)

(Date)