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Welcome to Array

Welcome to MetroChat

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Prefix

First Name *

Maiden Name

Last Name *

Sex *

Marital Status

Date of Birth

Passport/ID Number *

Select Policy *

Street Address

City

Country

Telephone Number

Cellphone Number *

Email Address *

Correspondence Language

Tax Paying

YesNo

Country of Tax Residence

Consent

You may be considered resident for tax purposes in a foreign jurisdiction if, for example: you live, work or earn money in a foreign jurisdiction; you are
a citizen or resident of a foreign jurisdiction; or other special circumstances apply to you.
You can be tax resident in more than one country at a time. Tax residency is complex and if you are uncertain you should consult your legal or tax
adviser. Metropolitan is obliged by International law to request this information which may be shared with tax authorities in foreign jurisdictions.

Prefix

First Name *

Maiden Name

Last Name *

Sex *

Marital Status *

Passport/ID Number *

Date of Birth *

Select Policy *

Street Address *

City *

Country *

Telephone Number *

Cellphone Number

Email Address

Correspondence Language

Tax Paying *

YesNo

Country of Tax Residence *

Consent *

You may be considered resident for tax purposes in a foreign jurisdiction if, for example: you live, work or earn money in a foreign jurisdiction; you are
a citizen or resident of a foreign jurisdiction; or other special circumstances apply to you.
You can be tax resident in more than one country at a time. Tax residency is complex and if you are uncertain you should consult your legal or tax
adviser. Metropolitan is obliged by International law to request this information which may be shared with tax authorities in foreign jurisdictions.

Employer’s Name

Cover Commencement Date

Broker / Person

Brokerage / Agency

Member Details

Prefix

First Name *

Last Name *

ID Number *

Date of Birth *

Employment No.

Race *

Residential Address *

City

ZIP / Postal Code

Country

Postal Address

City

ZIP / Postal Code

Country

Occupation

Preferred GP

Business Tel Number

Home

Mobile Number *

Email Address *

WhatsApp Number

Next of Kin (Name)

Relationship

Contact Number (Next of Kin)

Please select which option/plan you want to be registered *AccessStandardAdvancedComprehensiveHospital PlusGoldBronze

Dependant's Information

Name

Date of Birth

ID Number

Relationship

Name

Date of Birth

ID Number

Relationship

Name

Date of Birth

ID Number

Relationship

Name

Date of Birth

ID Number

Relationship

Name of Bank

Branch Name

Branch Code

Name of Account Holder

Account Number

Account type

SavingsCurrentTransmission

Premium Banking Details

Name of Bank

Branch Name

Branch Code

Name of Account Holder

Account Number:

Date Of Deduction

1st10th20th25th

Amount

Chronic Disease Condition

Full Names

Condition

Treatment Administered

Last Date of Treatment

Full Names

Condition

Treatment Administered

Last Date of Treatment

Full Names

Condition

Treatment Administered

Last Date of Treatment

Full Names

Condition

Treatment Administered

Last Date of Treatment

Medical History

Checkbox

Heart & Vascular SystemLungsDigestive System, Gall bladder & LiverNervous SystemBone, Muscle & JointsUrinary TrackGynaecological SystemMale Genital SystemGland/ HormonalBloodEar, Nose &ThroatEyesEmotional/Psychological ProblemsInfectious/Tropical DiseasesSkin DisordersTeeth & GumsCancerPregnancy

If yes to any of the previous questions, please state

Condition Name

Patient Name

Treatment

Doctor /Hospital

Last date of treatment

Condition Name

Patient Name

Treatment

Doctor /Hospital

Last date of treatment

Consent *

MHL may cancel your membership immediately or propose new terms of admission if you and those that you apply for:
(a) Provide MHL with information that is inadequate, untrue, and irrelevant to this application
(b) Do not inform MHL about any relevant changes (including the change in state of health) between the date you sign this document and the date of membership commencement or acceptance by MHL
(c) Do not fully disclose the medical conditions during the time of application

2. MHL may require member’s health information from attending medical practitioner or any provider, signing of this form authorises the scheme to do so if there is any need.

3. Waiting periods may apply in certain circumstances to your membership. This means there may be a set time period before MHL start paying for any general or specific conditions.

4. It is inapropriate to be a member of more than one medical scheme at the same time.

5. Membership is open to any individual or employee of an employer and shall be compulsory in respect of employee who, in terms of his conditions of employment is required to be a member of this scheme.

6. No persons aged 65 (for corporates), 55 (Individuals) or above and no special dependant aged 55 years of age or above shall be eligible for membership of the scheme unless special approval for this has been granted by the company in its sole discretion on application by member ,employee or individual concerned and after submission of supporting medical reports.

7. An existing member may continue to be a member of the scheme with his registered dependents, if any, in the event of retiring from service of his Employer or if his employment is terminated by his employer on account of age or any reasons other than age. Members must apply to be individual members.

8. It is the responsibility of a member to ensure that contributions are paid on time every month to avoid suspension of benefits or even termination, by signing this form members authorise the employers to deduct contribution from their salaries (for corporates) and the scheme to deduct from their bank accounts (for debit order payments).

9. It is the responsibility of a member to inform the scheme of the intention to terminate his membership, one month notice shall be served and membership cards should be returned to the scheme as use of cards after termination is illegal.

10. Members must call MHL MEMBER ENQUIRY SERVICES with regards to any queries and pre-authorisation

I certify that the information given above is correct. I agree that should my application be accepted, I will abide by the rules, benefits and regulations set by Metropolitan Health; details of which is available on request. Signing of this contract signifies the basis of contract between Metropolitan Health and myself.