GLA Lagos (HQ) - GLA Health Insurance

GLA Health Insurance

At GLA, we believe that access to quality healthcare should be a fundamental right for everyone, regardless of age, gender, or family size. That's why we're thrilled to announce the GLA Health Insurance Scheme, a comprehensive healthcare solution designed for individuals and families. Your health matters, for your body is the temple of the God. We desire that all walk in Divine Health.

GLA Health Insurance form

Main Sponsor

First Name

Last Name

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Marital Status

Family

Yes

Form is limited to Family of 5 persons, if you exceed 5 persons please reach out to the GLA empowerment Committee on the following emails. GLAEconomicEmpowerment@gmail.com,
EconomicEmpowerment@guidinglight.org.ng

Spouse details

First Name

Last Name

Date of birth

Gender

Dependent 1

First Name

Last Name

Date of birth

Gender

Dependent 2

First Name

Last Name

Date of birth

Gender

Dependent 3

First Name

Last Name

Date of birth

Gender

Occupational Status

Currently Unemployed

Self Employed

Seasonally/ temporarily employed

Fully Employed

Currently seeking employment

Yes

Name and Address of Business (if self employed )

Name and Address of Company (If employed)

Educational Institution (If in school)

Why do you think you should receive this Health Insurance Gift

GLA membership

Yes

Department

HOD's name

_{^{Write the next in the following format}}
_{^{SOURCE / DEPARTMENT.PURPOSE.TYPE(e.g. LOAN, GRANT).,AMOUNT,STATUS(e.g. REPAID, FORGIVEN, OUTSTANDING}}

State Previous Financing accessed from Church 1

State Previous Financing accessed from Church 2

State Previous Financing accessed from Church3

State Previous Financing accessed from Church4

NOTE: BY FILLING AND SUBMITTING THIS FORM YOU AGREE:
1. That you are providing true and accurate information about yourself and other potential beneficiaries.
2. That you may be disqualified if any information provided is found to be false or misleading.
3. To comply with the terms and conditions as may be explained from time to time.
4. To be accountable to a mentor that may be assigned.
5. To undergo a screening interview session by the selection committee.

Signature

< Back

Next >

Submit