Premier Service Medical Aid Society

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Level of protection$40.00

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Level of protection$40.00

PSMAS ONLINE REG FORM
PSMAS ONLINE REGISTRATION FORM - INDIVIDUAL

Step 1 / 5

SELECT PLAN:(Required)


INDIVIDUAL PLAN
SHIELD PLAN


PSMAS ONLINE REGISTRATION FORM - PRIVATE SECTOR

Step 2 / 5

MEMBERS'S DETAILS:

Title: Initials:
Name: Surname:
Cell Number:
DOB:
Telephone: ID Number:
-
Email: Gender:
Postal Address: Family Doctor
(Town) Below State other medical aid cover, if any:
(City)
(Country) Previous Memberhip #

PSMAS ONLINE REGISTRATION FORM - PRIVATE SECTOR

Step 3/ 5

EMPLOYMENT & BANKING DETAILS:

(Employment Details)

Employer Name: EC Number:
Postal Address: Employment Date:
(Town)
(City)
(Country)

(Banking Details)


Account Name: Account #:
Bank Name: Branch & Code:

PSMAS ONLINE REGISTRATION FORM - PRIVATE SECTOR

Step 4 / 5

BENEFICIARY(S) DETAILS:(When you done entering each dependant details click Add Dependant)

Gender: Relationship:
Title: Initials:
Name: Surname:
Plan: DOB:
ID Number:
-
Marriage Date:
 



PSMAS ONLINE REGISTRATION FORM - PRIVATE SECTOR

Step 5 / 5

FINAL STEP:

I declare that the information given above is true and l agree to abide by the rules, regulations and benefits as amended from time to time by the Society should my application be accepted. I authorise the deduction of the monthly subcriptions and any shortfalls due for myself and my beneficiaries from my salary or bank account.


If Agent,Click here