Secure Your Health Today

This enrollment is attributed to AMMBAN and handled by Agent Agent.

First Name

Last Name

Gender

Date of Birth

NIN (Optional)

Next of Kin (Optional)

Phone Number

State

LGA

Preferred Hospital

Insurance Plan

Only monthly and yearly plans are available for recurrent payment.

Payment Method

Total Amount

NGN 0.00

Direct Debit Setup

Enter the bank details that should be enrolled for recurring debit.

Recurring payment

Bank

Account Number