Bankmed Member Dependant Form
Please complete with up to date information.
Fund
Option
Bankmed Essence
Bankmed Essence Hospital
Bankmed Prime
Member
Number
Dependant
Code
Main Member
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Group
Number
Birth Date
Surname
First Name
ID /
Passport No.
Nationality
Namibian
South African
Postal
Address 1
Postal
Address 2
Postal
Address 3 & 4
Region
Erongo
Hardap
Karas
Kavango East
Kavango West
Khomas
Kunene
Ohangewena
Omaheke
Omusati
Oshana
Oshikoto
Otjozondjupa
Zambezi
Physical
Address
Suburb
Town
Area
Code
Phone
Area
Code
Work Phone
Fax
Cell No.
Next of Kin
Surname
Next of Kin
First name
Next of Kin
Relationship
Next of Kin
Contact No.
Next of Kin
Cell
Next of Kin
Physical Addr.
1
Next of Kin
Physical Addr.
2
Next of Kin
Physical Addr.
3 & 4
