Schlumberger Post Employment Medical Programme

This form is to be completed by the HR Manager. Please ensure that all necessary details are provided.
Section 1 tells us about the employee;
Section 2, if relevant, is for providing employee family information;
Section 3 (Company Details) must be completed for invoicing purposes. Thank you.

1. Employee Details

PLEASE MAKE SURE ALL DETAILS ARE CORRECT. CARDS WILL BE ISSUED WITH THESE DETAILS.

Last Name/Family Name
First Name
GIN Number
Nationality
Gender

Date of Birth

Email Address
Country of Residence upon termination
Home Address
The Bupa ‘welcome pack’ will be delivered to this address

Post Code
Do you want the membership cards/ pack to be couriered to you?YesNo
Coverage typeSingle LifeFamily

2. Applicant Family Details

Family Details

New Member

Last Name/Family Name

First Name

Nationality

Relationship to Applicant

Gender

Date of Birth

Last Name/Family Name

First Name

Nationality

Relationship to Applicant

Gender

Date of Birth

Delete Member

Not applicable

3. Bupa cover details

Applicant's start date of eligibility
(first day following termination)

Duration of Cover

The PEMP cover entitlement period is subject to the employee’s SLB seniority at the time of departure.

SLB Seniority	PEMP cover entitlement (months)*
2-5 years	3
5-10 years	6
10 years +	12

Duration of cover
Is the member eligible for USA cover? (This is at an additional cost) Please tick correct boxYesNo

4. Company Details

Legal Entity Full Name
Legal Entity Full Address
(for invoicing)
Post Code
HR Contact Full Name
HR Contact Email Address
Finance Information
Please provide any details here that are necessary for the processing of this invoice such as cost code

Does this invoice require a Purchase Order for processing?YesNo
Invoice submission email