SECTION I: EMPLOYER ACCOUNT HOLDER DETAILS Employer Name Cover Commencement Date Subsidairy / Division SECTION II: MEMBER DETAILS Firstname (required) Surname (required) National ID (required) Date Of Birth (required) Your Email (required) Residential Address Mobile Number MaleFemale SECTION III: PLEASE SELECT PLAN Universal PlusUniversal LiteSupremeSuperiorVitalEssentialBase SECTION IV: DETAILS OF YOUR GENERAL PRACTITIONER Name Address Contact Phone SECTION V: DEPENDANTS INFORMATION Name DOB ID No Gender Relationship Mobile Number SECTION IV: BANKING DETAILS Name of Bank Branch Branch Code Account Number By submitting this form you accept the Terms & Conditions [recaptcha size:compact] Fill in the forms and email to membership@cellmed.co.zw. You can also send physically to: CellMed Health Medical Fund The Honey Comb 5th Floor Finsure House 84-86 Kwame Nkrumah Avenue