LASU Staff Health Insurance Scheme Registration Form [Download in PDF]

SCHOLARSHIPS & OPPORTUNITIES

Lagos State University (LASU) Staff Members Lagos State Health Insurance Scheme (LSHISC) Registration Form, Guidelines and Submission Process [Download in PDF].

Following the sensitization webinar held on 9th June 2020 during which LASU staff members expressed positive attitude and willingness to participate in the Lagos State Health Insurance Scheme, the need to begin registration has become necessary.

The assigned Health Management Organization (HMO) – AXA MANSARD has expressed willingness to commence registration of our students, staff members and their dependants immediately.

Please click below to download form

• Download Form

The registration form is to be printed by the staff, completed with passport photographs of the staff and his/her dependants and submitted at the Health Centre. Officials of AXA MANSARD will pick the completed forms from the Health Centre.

Thank you.

LAGOS STATE HEALTH INSURANCE SCHEME (LSHS) REGISTRATION FORM SAMPLE

Affix The Principal Passport Photograph

Affix Spouse Passport Photograph

Affix Child 1 Passport Photograph

Affix Child 2 Passport Photograph

Affix Child 3 Passport Photograph

Affix Child 4 Passport Photograph

First Name: Middle Name: Surname:
Date of Birth: Gender: Marital Status: Title: (Mr, Mrs, Prof, Chief, Dr, Miss)
Blood Group: Nationality: State of Origin: Phone Number(s):
Email: Physical Address:
State of Residence: LGA of Residence: Ward: Postal/Zip Code:
Preferred Hospital: LASRRA ID Oracle Number(For Staff Only):
Employer:Spouse and Children Details( Leave Blank If you have no Spouse or Children)Name of Spouse: Title: Gender:
Date of Birth: State of Origin: Phone Number:
Email: Blood Group: LASRRA ID: Oracle Number:
Name of Child1: Date of Birth: Gender: LASRRA ID:
Blood Group: Email: Phone Number(If any):
Name of Child2: Date of Birth: Gender: LASRRA ID:
Blood Group: Email: Phone Number(If any):
Name of Child3: Date of Birth: Gender: LASRRA ID:
Blood Group: Email: Phone Number(If any):
Name of Child4: Date of Birth: Gender: LASRRA ID:
Blood Group: Email: Phone Number(If any):POLICY HOLDER SIGNATURE:__________________________