Change of Employer

1. Principal Member Details - To completed by the principal member

Membership Number

Title

First Name (s)

Surname

ID/ Passport No

Male / Female

Male

Female

Nationality

Home Phone

Contact Number

Work Phone

Alternative Number

Postal Address

Physical Address

2. Your Health Plan (Please tick one box only)

Health Plans

ISS (Student)

Access

Comprehensive

Executive

Prestige

Please select the desired level of cover under the chosen Health Plan

Core

Plus

Extra

Max

3. Dependants (to be included in the membership)

Re-order	Dependants Names	Relation to member	Dependants ID Number	Date of Birth	Weight	Operations
	Dependants Names	Relation to member	Dependants ID Number	Date of Birth	Item weight

more items

Call Us : 3633100

Gaborone

Plot 50638, Fairgrounds, Gaborone
P O Box 632, Gaborone, Botswana
BOMAID, 8WCF+J3F, Gaborone
Tel: +267 318 3100, +267 363 3101
Email: bomaid@bomaid.co.bw

Francistown

Plot 21931/21932
Tebo House, Ground Floor
P.O.Box 3328, Francistown, Botswana
Tel: +267 241 0316
Email: bomaid@bomaid.co.bw

Maun

Engen Center - New Mall Plot 1196
Tel: +267 686 4577
Email: bomaid@bomaid.co.bw