Who are you buying this plan for? Myself Someone Else Family / Group Personal InformationGender *MaleFemaleSurname *Other Name(s) *Genotype *Select your GenotypeAAASACSSSCCCDate of Birth *Select day12345678910111213141516171819202122232425262728293031Select month123456789101112Select Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950Contact InformationEmail Address *Phone Number *Contact Address / Mailing Address *State of Origin *Select a StateAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraFederal Capital Territory – AbujaLGA *Upload Identification *Choose FileNo file chosenDelete uploaded filee.g Driver’s License, National ID Card, International Passport (Max file size: 2MB)Other InformationPreferred Hospital Location *Select LocationAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraPreferred Hospital *Pre-existing health conditions? *YesNoHealth condition(s)Heart and Artery DiseasesEndocrinology Diseases including DiabetesLung Disease Kidney and Urinary tract DiseasesMuscles, Bones and Joints DiseasesHaematology DiseasesEar, Nose, Throat and Eye DiseasesMalignant Tumours or CancerSexually Transmitted DiseasesCongenital DiseasesNervous system DiseasesGastroenterology DiseasesPreviously Undergone any surgery due to a disease or an accidentCurrently take any medicines on a frequent regular or permanent basis Suffer from allergies to any medication food other environmental factorsMarried women only! Are you currently pregnant?By proceeding, you agree to our privacy policy. For further enquiries, please contact us.Submit Sponsor DetailsGender *MaleFemaleSurname *Other Name(s) *Email Address *Phone Number *Contact Address / Mailing Address *Upload Identification *Choose FileNo file chosenDelete uploaded filee.g Driver’s License, National ID Card, International Passport (Max file size: 2MB)Beneficiary InformationBeneficiary's Gender *MaleFemaleBeneficiary's Surname *Beneficiary's Other Name(s) *Beneficiary's Email Address *Beneficiary's Phone Number *State *Select a StateAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraTown *Beneficiary's Age *Relationship with Beneficiary *Select RelationshipSonDaughterHusbandWifeBrotherSisterMotherFatherOthersPreferred Hospital Location *Select LocationAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraFederal Capital Territory – AbujaPreferred Hospital *Other InformationPre-existing health conditions? *YesNoHealth condition(s)Heart and Artery DiseasesEndocrinology Diseases including DiabetesLung Disease Kidney and Urinary tract DiseasesMuscles, Bones and Joints DiseasesHaematology DiseasesEar, Nose, Throat and Eye DiseasesMalignant Tumours or CancerSexually Transmitted DiseasesCongenital DiseasesNervous system DiseasesGastroenterology DiseasesPreviously Undergone any surgery due to a disease or an accidentCurrently take any medicines on a frequent regular or permanent basis Suffer from allergies to any medication food other environmental factorsMarried women only! Are you currently pregnant?By proceeding, you agree to our privacy policy. For further enquiries, please contact us.Submit Principal DetailsGender *MaleFemaleSurname *Other Name(s) *Email Address *Phone Number *State of Origin *Select a StateAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraFederal Capital Territory – AbujaLGA *Contact Address / Mailing Address *Date of Birth *Select day12345678910111213141516171819202122232425262728293031Select month123456789101112Select Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950Preferred Hospital Location *Select LocationAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraFederal Capital Territory – AbujaPreferred Hospital *Upload Identification *Choose FileNo file chosenDelete uploaded filee.g Driver’s License, National ID Card, International Passport (Max file size: 2MB)Pre-existing health conditions? *YesNoHealth condition(s)Heart and Artery DiseasesEndocrinology Diseases including DiabetesLung Disease Kidney and Urinary tract DiseasesMuscles, Bones and Joints DiseasesHaematology DiseasesEar, Nose, Throat and Eye DiseasesMalignant Tumours or CancerSexually Transmitted DiseasesCongenital DiseasesNervous system DiseasesGastroenterology DiseasesPreviously Undergone any surgery due to a disease or an accidentCurrently take any medicines on a frequent regular or permanent basis Suffer from allergies to any medication food other environmental factorsMarried women only! Are you currently pregnant?Add Beneficiaries Add your beneficiary(ies) details below and select a health plan and hospital for them. Adding over 5 individuals? Contact our SALES TEAMSelect Beneficiary(ies)Beneficiary 1Beneficiary 2Beneficiary 3Beneficiary 4Beneficiary 5Beneficiary 1 InformationBeneficiary 1 GenderMaleFemaleBeneficiary 1 SurnameBeneficiary 1 Other Name(s)Beneficiary 1 Email AddressBeneficiary 1 Phone NumberBeneficiary 1 AgeRelationship with Beneficiary 1Select RelationshipSonDaughterHusbandWifeBrotherSisterMotherFatherOthersBeneficiary 1 Preferred Hospital LocationSelect LocationAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraFederal Capital Territory – AbujaBeneficiary 1 Preferred HospitalDoes Beneficiary 1 have any pre-existing health conditions?YesNoBeneficiary 1 Health condition(s)Heart and Artery DiseasesEndocrinology Diseases including DiabetesLung Disease Kidney and Urinary tract DiseasesMuscles, Bones and Joints DiseasesHaematology DiseasesEar, Nose, Throat and Eye DiseasesMalignant Tumours or CancerSexually Transmitted DiseasesCongenital DiseasesNervous system DiseasesGastroenterology DiseasesPreviously Undergone any surgery due to a disease or an accidentCurrently take any medicines on a frequent regular or permanent basis Suffer from allergies to any medication food other environmental factorsMarried women only! Are you currently pregnant?Beneficiary 2 InformationBeneficiary 2 GenderMaleFemaleBeneficiary 2 SurnameBeneficiary 2 Other Name(s)Beneficiary 2 Email AddressBeneficiary 2 Phone NumberBeneficiary 2 AgeRelationship with Beneficiary 2Select RelationshipSonDaughterHusbandWifeBrotherSisterMotherFatherOthersBeneficiary 2 Preferred Hospital LocationSelect LocationAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraFederal Capital Territory – AbujaBeneficiary 2 Preferred HospitalDoes Beneficiary 2 have any pre-existing health conditions?YesNoBeneficiary 2 Health condition(s)Heart and Artery DiseasesEndocrinology Diseases including DiabetesLung Disease Kidney and Urinary tract DiseasesMuscles, Bones and Joints DiseasesHaematology DiseasesEar, Nose, Throat and Eye DiseasesMalignant Tumours or CancerSexually Transmitted DiseasesCongenital DiseasesNervous system DiseasesGastroenterology DiseasesPreviously Undergone any surgery due to a disease or an accidentCurrently take any medicines on a frequent regular or permanent basis Suffer from allergies to any medication food other environmental factorsMarried women only! Are you currently pregnant?Beneficiary 3 InformationBeneficiary 3 GenderMaleFemaleBeneficiary 3 SurnameBeneficiary 3 Other Name(s)Beneficiary 3 Email AddressBeneficiary 3 Phone NumberBeneficiary 3 AgeRelationship with Beneficiary 3Select RelationshipSonDaughterHusbandWifeBrotherSisterMotherFatherOthersBeneficiary 3 Preferred Hospital LocationSelect LocationAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraFederal Capital Territory – AbujaBeneficiary 3 Preferred HospitalDoes Beneficiary 3 have any pre-existing health conditions?YesNoBeneficiary 3 Health condition(s)Heart and Artery DiseasesEndocrinology Diseases including DiabetesLung Disease Kidney and Urinary tract DiseasesMuscles, Bones and Joints DiseasesHaematology DiseasesEar, Nose, Throat and Eye DiseasesMalignant Tumours or CancerSexually Transmitted DiseasesCongenital DiseasesNervous system DiseasesGastroenterology DiseasesPreviously Undergone any surgery due to a disease or an accidentCurrently take any medicines on a frequent regular or permanent basis Suffer from allergies to any medication food other environmental factorsMarried women only! Are you currently pregnant?Beneficiary 4 InformationBeneficiary 4 GenderMaleFemaleBeneficiary 4 SurnameBeneficiary 4 Other Name(s)Beneficiary 4 Email AddressBeneficiary 4 Phone NumberBeneficiary 4 AgeRelationship with Beneficiary 4Select RelationshipSonDaughterHusbandWifeBrotherSisterMotherFatherOthersBeneficiary 4 Preferred Hospital LocationSelect LocationAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraFederal Capital Territory – AbujaBeneficiary 4 Preferred HospitalDoes Beneficiary 4 have any pre-existing health conditions?YesNoBeneficiary 4 Health condition(s)Heart and Artery DiseasesEndocrinology Diseases including DiabetesLung Disease Kidney and Urinary tract DiseasesMuscles, Bones and Joints DiseasesHaematology DiseasesEar, Nose, Throat and Eye DiseasesMalignant Tumours or CancerSexually Transmitted DiseasesCongenital DiseasesNervous system DiseasesGastroenterology DiseasesPreviously Undergone any surgery due to a disease or an accidentCurrently take any medicines on a frequent regular or permanent basis Suffer from allergies to any medication food other environmental factorsMarried women only! Are you currently pregnant?Beneficiary 5 InformationBeneficiary 5 GenderMaleFemaleBeneficiary 5 SurnameBeneficiary 5 Other Name(s)Beneficiary 5 Email AddressBeneficiary 5 Phone NumberBeneficiary 5 AgeRelationship with Beneficiary 5Select RelationshipSonDaughterHusbandWifeBrotherSisterMotherFatherOthersBeneficiary 5 Preferred Hospital LocationSelect LocationAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraFederal Capital Territory – AbujaBeneficiary 5 Preferred HospitalDoes Beneficiary 5 have any pre-existing health conditions?YesNoBeneficiary 5 Health condition(s)Heart and Artery DiseasesEndocrinology Diseases including DiabetesLung Disease Kidney and Urinary tract DiseasesMuscles, Bones and Joints DiseasesHaematology DiseasesEar, Nose, Throat and Eye DiseasesMalignant Tumours or CancerSexually Transmitted DiseasesCongenital DiseasesNervous system DiseasesGastroenterology DiseasesPreviously Undergone any surgery due to a disease or an accidentCurrently take any medicines on a frequent regular or permanent basis Suffer from allergies to any medication food other environmental factorsMarried women only! Are you currently pregnant? By proceeding, you agree to our privacy policy. For further enquiries, please contact us.Submit Selected Plan: Pera Ultra Cost: Individual: ₦347,402Family: ₦1,737,008
