joinflimas Application Type *Self PayerCorporate ClientPrincipal Member First Name/s *(Required)Principal Member Last Name *(Required)Residential Address *(Required)Email Phone(Required)Date of Birth(Required) DD slash MM slash YYYY Gender(Required)MaleFemaleOtherMarital Status(Required)SingleMarriedDivorcedWidowedNext of KinID Number(Required)OccupationEmployee NumberBank NameBranch CodeAccount NameAccount NumberPrevious Medical Aid MembershipSelect SchemeDeluxe Plus USDDeluxe Elite USDThird ChoiceAdd DependantsMedical History(Required) HYPERTENSION EPILEPSY RENAL LUNG BLOOD DISEASES STROKE CANCER LIVER PSYCHIATRIC NONE OF THE ABOVE OTHER Consent By submitting, you acknowledge that you have read and understood, and agree to FLIMAS Medical Aid Terms and Conditions
