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Employee Health Application form

Select Application Purpose

Employer-Subsidized (Earning up to R16 000 p/m)

Self-Funding (Earning over R16 000 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

Day

Year

Email*

Phone (Must be WhatsApp number)*

Address*

Gender*

Male

Female

Country of Origin*

Department/Site Name *

Upload Latest Payslip*

File upload*

Beneficiaries

Initials

First Name

Surname

ID/Passport Number

Date of Birth

Gender

Male

Female

Relation to employee

Upload ID/Passport

Beneficiaries

Initials

First Name

Surname

ID/Passport Number

Date of Birth

Relation to employee

Gender

Male

Female

Upload ID/Passport

Beneficiaries

Initials

First Name

Surname

ID/Passport Number

Date of Birth

Relation to employee

Gender

Male

Female

Upload ID/Passport

info@well2care.com

Well2Care

2 Bruton Rd, Bryanston, Sandton, 2191

Call: +27 082 820 1813

info@well2care.com

info@well2care.com

©2023 yi-Well2Care. Idalwe ngokuziqhenya nguCONNECTX

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