Service Request

Partner Registration

Join Ensuram's healthcare marketplace. Need help? Contact us at compliance@ensuram.com

Select Your Category

Choose the type of organization you represent

Insurance

Hospital

Pharmacy

Laboratory

Organization

Select the category that best describes your organization. This will determine your access level and features.

Contact Information

Provide contact details for your organization

Contact Person First Name *

Please enter first name

Contact Person Last Name *

Please enter last name

Contact Person Email *

Please enter a valid email address

Contact Person Phone *

Please enter phone number

Director's Name *

Please enter director's name

Director's Email *

Please enter director's email

Required Documents

Upload your organization's legal documents

Certificate of Incorporation *

Click to upload or drag and drop

PDF, JPG, PNG (Max 2MB)

Business License *

Click to upload or drag and drop

PDF, JPG, PNG (Max 2MB)

Director's ID *

Click to upload or drag and drop

PDF, JPG, PNG (Max 2MB)

Declaration & Signature

Review and sign the declaration

Declaration of Accuracy
The individual submitting this Service Request Form affirms that all information provided herein is true, accurate, and complete to the best of their knowledge. They understand that any false, misleading, or incomplete information may result in the delay, suspension, or termination of the onboarding process or service eligibility. The individual further agrees to promptly notify Ensuram Inc. of any changes to the information provided.

Your Name *

Please enter your name

Job Title *

Please enter your job title

Date Signed *

Please select date

Digital Signature *

Sign here

Security Verification *

Please answer the security question

Partner Registration

Select Your Category

Company Information

Contact Information

Required Documents

Declaration & Signature

Application Submitted Successfully!