Staff Enrolment Form - Orange Health Insurance

Unique Company Code *

Company/Employer Name *

Your Official Position/Role

Surname *

First Name *

Other Name(s)

Gender *

Date of Birth *

Ghana Card Number *

Phone 1 *

Phone 2

Email Address *

Town / District

Preferred Service Provider

Benefit Plan

History of Surgery

Other Known Pre-existing Medical Condition

Upload Document (Passport Picture, etc.)

I attest that the information I have provided above is true and accurate.

Signature (typed name) *

Client Enrolment Form