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NATIONAL HEALTH INSURANCE SCHEME

DHML/NHIS MILITARY PERSONNEL (SERVING) BIO-DATA FORM

ARMED FORCES SOCIAL HEALTH INSURANCE PROGRAMME (AFSHIP)

1.Personal Data:

Surname: First Name: Middle Name (Optional): 2.Service No: 3.State of Origin: Select State Abia Adamawa Akwa Ibom Anambra Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Edo Ekiti Enugu Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara FCT 4.Date of Birth: 5.Sex: Male Female

6.Marital Status

Select Marital Status: Select Single Married Divorced 7.Age: 8.Blood Group: A+ A- B+ B- AB+ AB- O+ O- 9.National ID (NIN): 10.Telephone Number: +234

11.State of Origin: Select State Abia Adamawa Akwa Ibom Anambra Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Edo Ekiti Enugu Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara FCT 12.Residential Address:

13.Employer

14.Rank And Rate

Select Option Rate Rank

15.Medical History

Select Medical Condition: Select Diabetes Epilepsy Hypertension Sickle Cell Disease Allergies Other

16. Dependant Provider's Data

Name (PHC): Code No (PHC):

17.Spouse Details

Spouse

Title: Select Title Mr Mrs prof Engr Chief Rev Dr Others First Name: Middle Name (Optional): Surname: Sex: Male Female Is the spouse a personnel? 18.Blood Group: A+ A- B+ B- AB+ AB- O+ O- 19.Date of Birth: 20.State of Origin: Select State Abia Adamawa Akwa Ibom Anambra Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Edo Ekiti Enugu Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara FCT 21. Local Government of Residence: Select State Abia Adamawa Akwa Ibom Anambra Bauchi Bayelsa Benue Borno Cross River Delta Ebonyi Edo Ekiti Enugu Gombe Imo Jigawa Kaduna Kano Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara FCT Select LGA

Children

Add Child

Dependent Details

Spouse Title: Select Title Select Title Mr Mrs prof Engr Chief Rev Dr Others Spouse Surname: Spouse First Name: Spouse Middle Name (Optional):