Personal Information
Home Address
Smoking Status
Select smoking status
Non-Smoker
Former Smoker
Occasional Smoker
Regular Smoker
Next: Medical History
Medical History
Do you have any of the following medical conditions?
List any current medications
List any allergies
Previous surgeries or hospitalizations
Family medical history
Next: Family Members
Family Members
How many family members (including yourself) need coverage?
1 (Just me)
2
3
4
5
6
7
8
Next: Coverage & Payment
Coverage & Payment Details
Payment Information
Preferred Payment Method
Select payment method
Credit Card
Bank Account (ACH)
PayPal
Payment Frequency
Select payment frequency
Monthly
Quarterly (Save 2%)
Semi-Annual (Save 3%)
Annual (Save 5%)
Next: Review & Submit
Review Your Application
Name:
Date of Birth:
Gender:
Email:
Phone:
Address:
Height:
Weight:
Smoking Status:
Medical Conditions: None selected
Medications: None listed
Allergies: None listed
Total Family Size: 1
No additional family members added.
Plan: ZenCare Prime (Family)
Coverage Start Date:
Payment Method:
Payment Frequency:
Estimated Premium: ₦399.99 per month
I confirm that all the information provided is accurate and complete to the best of my knowledge. I understand that any misrepresentation may result in the denial of claims or cancellation of coverage.