Fillable Corporate Membership Application Form1.

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Corporate Membership Application Form1.

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The Corporate Membership Application Form1. form is 4 pages long and contains:

  • 0 signatures
  • 6 check-boxes
  • 346 other fields

Country of origin: OTHERS
File type: PDF

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Once filled in please email the completed form and supporting documents
to
newapp@bomaid.co.bw OR fax to +267 3184152/ 230 OR drop off at
your nearest Bomaid office
Corporate Membership Application Form1.
1. Principal Member : Your personal details
0 1 M M Y Y Y Y D D M M Y Y Y Y
M F
S M D W
Certificate Diploma Degree
Masters
PHD Others
Cellphone 1
1) D D M M Y Y Y Y
Spouse Son Daughter
2) D D M M Y Y Y Y
Spouse Son Daughter
3) D D M M Y Y Y Y
Spouse Son Daughter
4) D D M M Y Y Y Y
Spouse Son Daughter
5) D D M M Y Y Y Y
Spouse Son Daughter
3. Your Scheme Cover - Level of cover (Please tick one box only)
Date of
Birth
Relationship to Main
Member
Date of
Birth
Relationship to Main
Member
Principal
Member's Signature
ID/ Passport
Number
Attach copy of your ID or Passport. Application will NOT be processed without this document.
First Name (s)
Surname
ID/Passport
No.
Home Phone
Title
Male / Female
(Please tick where applicable)
Nationality
Educational
Background
Marital Status
Date of Birth
Specify date you
want cover to start
2. Dependants (to be included in the membership)
Attach copy of your marriage certificate & spouse's ID /Passport, Children's birth certificates or Police sworn affidavits (if you do not have your children 's birth certificates ) if you
are adding them as your dependants. Application will NOT be processed without these documents
ID/ Passport
Number
Physical Address
ID/ Passport
Number
Date of
Birth
Relationship to Main
Member
Date of
Birth
Relationship to Main
Member
ID/ Passport
Number
ID/ Passport
Number
Membership
Number
Parent/
Parent in Law
Parent/
Parent in Law
Parent/
Parent in Law
Parent/
Parent in Law
Parent/
Parent in Law
Date of
Birth
Relationship to Main
Member
Work Phone
Cellphone 2
Personal Email
Address
Work Email
Address
Postal Address
Gross Monthly
Salary (in BWP)
A A+ B B+ C C+ A Standard
4. Employment details (New companies should enclose a copy of their certificate of incorporation)
D D M M Y Y Y Y
D D M M Y Y Y Y D D M M Y Y Y Y
Other
5. Applicant’s banking details
(for Claim Refunds)
Current/Cheque Savings Credit Card Transmission
6. Next of Kin's Details
Spouse Son
Daughter
Relationship to Main
Member
Parent
Full Names
Attach copy of your latest payslip OR confirmation of employment letter. Application will NOT be processed without this document.
Attach copy of your bank statement OR bank letter confirming the below banking details. Application will NOT be processed without this document.
Payer's Full Names
Agriculture
Mining &
Quarrying
Health
Real Estate
Education
Company Stamp/Representative Stamp
Name of Previous Or
Current Medical Insurer
Date of Employment
Start DateCover Period From Previous Insurer
Position Held
End Date
Branch Name
Payer's Bank Name
Employer to stamp below OR attach a formal letter instructing Bomaid to add member under their company billing.
Hotels &
Restaurants
Finance
Transport &
Communication
Account Number
Manufacturing
Construction
Email Address
Name of Current
Employer
Wholesale &
Retail Trade
Electricity &
Water
Account Type
Cellphone Number
Economic Sector
7. Confidential Medical History
D D M M Y Y Y Y
8. Additional information
This section applies if you have indicated “YES” to any questions in section 6.
8. Nervous or mental complaint e.g. epilepsy convulsions, dizziness, blackouts, paralysis meningitis,
anxiety states, depression, alcoholism meningitis, anxiety states, depression, alcoholism
9. Ear, eye, nose, throat problem, including ear discharge, hearing loss, defective vision tonsillitis,
grommets’, injuries, or any other ENT disorders?
10. Diseases of the reproductive system e.g infertility, ovarian cysts, uterine fibroids, abnormality of
pregnancy or confinement or any other related reproductive system disorder?
11. Expecting or planning to have a baby?
If you have
indicated 'yes' please state the expected delivery dates
1st
Dependant
2nd
Dependant
3rd
Dependant
4th
Dependant
5th
Dependant
List details of medications used in
the last twelve months and related
conditions?
Principal
Member
1st
Dependant
2nd
Dependant
3rd
Dependant
4th
Dependant
The relevant question number from
section 6
When last did you see your doctor and
for what reason?
Do you have any chronic conditions
that may need medical attention within
the next twelve months?
12. Sexually transmitted diseases e.g syphilis. gonorrhoea, HIV /AIDS related illness or any other
sexually transmitted diseases?
13. Any physical disabilities or injuries?
14. Any congenital disease/disability?
15. Any special dental treatments e. crown bridge prosthodontic and orthodontic appliances or any
other dental problems?
Principal
Member
Please tick either Yes or No to each of these questions, Do you have, or have you ever had any of the
following? If you've indicated 'Yes' please state the condition below the respective question
1. Shortness of breath, palpitations, raised cholesterol, stroke, raised blood pressure, heart murmur,
angina, heart attacks or other cardiac/vascular disorder?
2. Difficulty when breathing, persistent cough, tuberculosis, asthma, bronchitis pneumonia, croup or
any other related respiratory disorder?
3. Nephritis, prostrate problems, kidney stone, congenital kidney disorder, albumen in urine, uraemia
or any other urinary/kidney disorder?
4. Diabetes, sugar in blood/urine, glandular, disorder, goitre or any other endocrine disorder?
5. Conditions of joints or spine including rheumatism, arthritic, neck or back disorder?
6. Any lumps, growths (benign or malignant cancer, Hodgkin’s disease, leukaemia, skin cancer, lesion
or any other related problems?
7. Ulcers (gastric or duodenal hiatus, hiatus cancer, lesion or any other related problems dysentery,
gastro-intestinal or abdominal obstructions or any other related disorders?
5th
Dependant
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
16. Are you a smoker?
9. Your doctors' details
IMPORTANT INFORMATION
Dual membership: No dual membership is allowed.
How did you get to know about Bomaid?
Social Media Employer TV
Website Print Media Family/ Friends
Other
Disclaimer
I/ We Declare that the information on this form is to the best of my knowledge true and correct. I/We further acknowledge that Botswana Medical Aid
Society accepts no responsibility or liability for the accuracy of the information provided by myself. If I am illiterate, I confirm that the contents of this
application form and the implications thereof have been read and explained to me.
D D M M Y Y Y Y
FOR OFFICIAL USE ONLY
D D M M Y Y Y Y
Doctor's name
Email Address
Landline Mobile number
Please be aware that this form must be received by Botswana Medica Aid
Society no more than six weeks after the declaration date.
It is advisable that you fill in your form with complete up-to-date medical
history before you sign and date this form.
Comments
Signature
Please register new-borns within seven working days
with or without birth certificate
Email copy of birth certificate to bomaid@bomaid.co.bw OR membership@bomaid.co.bw
Adding a spouse: Please attach a copy of your marriage certificate and
copy of ID/Passport.
Adding a child dependant: Please attach a copy of the birth certificate or affidavit.
Confidentiality: All member information given to Bomaid is guaranteed to be
confidential and shall only be used for purposes related to customer service.
Date signedSignature
Date Signed
Agent Name
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Completed 18 August 2021

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