Family Form December Plan - Leadway Health

Selected Plan: December 1

Personal Information

First Name

Surname

Other Name

Gender

Male

Female

Phone Number

Date of Birth

Marital Status

Upload Passport Photo

Selected Plan: December 1

Contact Information & Identification

Address

State

Town

Identification type

Enter Identification Number

Selected Plan: December 1

Other Information

Do you have any current medical condition that requires ongoing treatment?

YES

Selected Plan: December 1

Beneficiary

First Name

Surname

Relationship

Gender

Date of Birth

Mobile Number

Upload Passport Photo

Declaration & Payment

I consent to the use of my information to further process my request and also acknowledge that I have read and understood our Terms & Conditions and Privacy Policy

I declare that to the best of my knowledge, I and any other person to be insured in this application have provided the accurate information at the point of registration and the insurer is indemnified should a claim arise due to information withheld from this application.

I understand that certain conditions such as maternity care, intensive care, surgeries, optical care and psychiatric care may be subject to a condition specific waiting period specified on the Benefit Table and therefore will not be covered from the beginning of the policy

Selected Plan: December 1

Personal Information

Selected Plan: December 1

Contact Information & Identification

Identification type

OR

Selected Plan: December 1

Other Information

Selected Plan: December 1

Beneficiary

Declaration & Payment

Total Payment: ₦

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