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C4C

CARE FOR CAREGIVER (“C4C”) MEDICAL INSURANCE SCHEME

APPLICATION FORM

Personal Details (Principal Scheme Holder)

First Name

Last Name

Title

Gender

Male

Female

Work Station

Specialty

Residential Address:

Residential Address

City

Date of Birth

NRC/Passport Number:

Preferred communication:

Call

E-mail

ALL

Next of Kin

First Name

Last Name

Title

Gender

Male

Femal

Relationship

Residential Address:

Address

Benefits Package Limits:

Gold Package

Beneficiaries

Principal Member (No age limit)

Beneficiary 1 (Age limit: 65 years old)

Beneficiary 2 (Less than 21 years old)

Beneficiary 3 (Less than 21 years old)

Beneficiary 4 (Less than 21 years old)

Beneficiary 5 (Less than 21 years old)

Beneficiary 6 (Less than 21 years old)

ATTACHMENTS

Bank Account Details

Name: Zambia Medical Association Savings

Bank: ABSA

Account Number: 017-1570220

Branch: Longacres

Sort Code: 020017

Swift Code: BARCZMLX

NB. Remember to use your name as narration on ALL transactions.

I acknowledge that I have read the terms and conditions of the C4C medical scheme. I have understood my obligations and those of the scheme providers and decided to subscribe to this scheme out of my own volition. I further declare that the information provided herein this application is accurate and has not been altered in any way.

Date

Correspondence

Cell: +260 977 486 800

Email: c4c@zma.co.zm