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Employee Health Application form
Select Application Purpose
*
Employer-Subsidized (Earning up to R17 100 p/m)
Self-Funding (Earning over R17 100 p/m)
BHealthi Member Adding Dependent Only
Uncovered or Medical Aid Member Adding Dependent
On Medical Aid, Want to Join BHealthi EHP
Title
*
Employee Number
*
Initials
*
First name
*
Last name
ID/Passport Number
*
Birthday
*
Month
Month
Day
Year
Email
*
Phone (Must be WhatsApp number)
*
Address
*
Gender
*
Male
Female
Country of Origin
*
Department/Site Name
*
Branch Point
*
Choose one
Upload Latest Payslip
*
Upload File
File upload
*
Upload Copy of ID/Passport
Beneficiaries
Initials
First Name
Surname
ID/Passport Number
Date of Birth
Gender
Male
Female
Relation to employee
Upload ID/Passport
Upload file
Beneficiaries
Initials
First Name
Surname
ID/Passport Number
Date of Birth
Relation to employee
Gender
Male
Female
Upload ID/Passport
Upload File
Beneficiaries
Initials
First Name
Surname
ID/Passport Number
Date of Birth
Relation to employee
Gender
Male
Female
Upload ID/Passport
Upload File
Signature
*
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Submit
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