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ENROLLMENT

Application for CUFM Enrollment and Group Family Shield Cover

Fill the form below, get your Application ID and make your payment online / bank.

If you have previously enrolled and want to pay, CLICK HERE

YOUR SPONSOR

Do you have a sponsor?

Sponsor

BIO DATA

Who is Insured

Title

Surname

Other Names

Gender

Date of Birth

ID Type

ID Number

Contact Address

City

State

Phone

Occupation

Marital Status

BENEFICIARY DETAILS

Beneficiary 1

Surname

Other Names

Date of Birth

Phone

Relationship

Benefit ( % )

Beneficiary 2

Surname

Other Names

Date of Birth

Phone

Relationship

Benefit ( % )

Please ensure that you confirm your Sponsor's Details Above before Submitting.

SELECT PAYMENT OPTION

PAY OPTION

Amount * N250.00 transaction fees

PAYING TO THE BANK

CUFM Bank A/C

Slip / Teller No

Amount

Depositor Name

Deposit Date

ENROLLMENT

YOUR SPONSOR

BIO DATA

BENEFICIARY DETAILS

Enter the email you used for enrolling