Afya Salama

Benefits of the Shared Community Health package for: 1 Principal member with up to 3 dependents Benefit Covers up to: Outpatient - Tzs 450,000 Inpatient - Tzs 3,000,000 Delivery - Tzs 600,000 1 Principal member with up to 2dependents Benefit Covers up to: Outpatient - Tzs 400,000 Inpatient - Tzs 2,750,000 Delivery - Tzs 600,000 1 Principal member with up to 1 dependent Benefit Covers up to: Outpatient - Tzs 350,000 Inpatient - Tzs 2,500,000 Delivery - Tzs 600,000 1 Principal member only Benefit Covers up to: Outpatient - Tzs 300,000 Inpatient - Tzs 2,000,000 Delivery - Tzs 600,000 Note: Age Limit Principal and Spouse - 70 years Children 21 years

Principal Member + 3 Dependents

TSh 200,000.00

Principal Member + 2 Dependents

TSh 200,000.00

Principal Member + 1 Dependent

TSh 200,000.00

Principal Member only

TSh 200,000.00

Quantity

Principal Member Name

Principal Member Age

Principal Member Date of Birth

Principal Member Mobile number

Principal Member Email address

Optional

Principal Member Address Street, Ward, District,Region

Name the dependent 1 - relationship - Age eg Asha Halfan - Wife, Juma Halfan- Child, Fatma Halfani - Child

Optional

Name the dependent 2 - relationship - Age eg Asha Halfan - Wife, Juma Halfan- Child, Fatma Halfani - Child

Optional

Name the dependent 3 - relationship - Age eg Asha Halfan - Wife, Juma Halfan- Child, Fatma Halfani - Child

Optional