Corporate Membership Application

Group Name

Address

Primary Contact Person

Nature of Business

Total Members of empoyess

Platinum

Number of members

Number of dependants

Gold

Number of members

Number of dependants

Bronze

Number of members

Number of dependants

Silver

Number of members

Number of dependants

Please state your medical expenditure for the previous two years (actual or estimate)

Year One

Year One Amout

Year Two

Year Two Amout

Submitted By

I HEREBY DECLARE TO THE BEST OF MY KNOWLEDGE THAT THE ABOVE INFORMATION IS CORRECT