INDIVIDUAL LIFE INSURANCE PROPOSAL FORM

“An Insurance Agent who assists an applicant to complete application or proposal form for insurance shall be deemed to have done so as the agent of the applicant – Section 54 (2) Insurance Act, 2003”.

DETAILS OF THE PERSON TO BE INSURED (Person to be covered by the insurance policy)

Surname(*)

First Name(*)

Middle Name

Title(*)

Maiden Name(*)

Gender(*)

Date of Birth(*)

Place of Birth (*)

Nationality (*)

Marital Status:(*)

Name of Spouse(*):

State of Origin (*)

Local Government of Origin(*)

Religion(*)

Ocupation (*)

Designation(*)

Email Address(*):

Mobile Number (*)

Tel No(*)

Residential Address(*):

Contact Address (if different from above)(*):

Landmark Close to your Place of Residence (e.g. Police Station, Market Place, Bus Stop etc)(*):

IDENTIFICATION

Indentification type (*)

Other (Specify)(*)

Issue Date(*)

Expiry Date(*)

Identification Number (*)

Passport Photo(*)

BANK ACCOUNT DETAILS

Bank Name

Bank Account Number

Bank Branch

Account Name

BVN

OCCUPATION

Type of Employment(*):

Name of Employer(*):

Address of Employer(*):

Email Address of Employer(*):

Date Employed

Tel No. of Employer

HEALTH INFORMATION

WHAT IS YOUR PRESENT:

Height (metre):

Weight:

Sports Engagement:

Do you have any Bodily Infirmity?(*):

Have you had Heart Condition, a Stroke, Hypertension, Paralysis, Cancer, Diabetes, Kidney Failure, Liver Failure, Mental Illness,
HIV Infection or AIDS?(*):

Do you currently have, or are you receiving treatment for any Symptoms, Medical Conditions or Disabilities?(*):

Have you been absent from work due to Illness or Injury for a continuous period of more than 10 days during the past one year?(*):

Are you currently pregnant? (for females only) :

If Yes, when is your Expected Date of Delivery? :

Name of Doctor: :

Doctor’s Address: :

HABIT

Do you smoke, drink alcohol, or take any medicines regularly (e.g stimulants, antibiotics, sedatives etc.) :

Do you have intentions or expectations of engaging in aviation (other than as a fare paying passenger)?:

If Yes to either, Give Details::

DETAILS OF COVER

Name of the Heirs Life Assurance Product You Want to Buy::

Commencement Date

Duration of Cover (years):

Sum Assured (N):

Premium (N):

Frequency of Premium Payment:

Preferred Mode of Payment:

OTHER INFORMATION

Are there any Additional Facts Affecting the Risk of Assurance on Your Life of which the Company Should Be Made Aware? :

If Yes, Give Details::

DECLARATION:

I/, the Life to be assured, do hereby declare that I am at present in good
health and that the statements in this proposal are true and complete. I consent to Heirs Life Assurance Ltd (the Company) seeking medical evidence
from any doctor who at any time has attended to me and/or seeking information from any insurance company to which I have at any time made a
proposal for life assurance and I authorize the release of such information.

I further declare that to the best of my knowledge the statements in this proposal are true and complete, and together with statements which may be
made to the Company’s medical examiner shall be the basis of the contract between me and the Company.

Name of Proposer :

Signature of Life to be Assured

Date (*)

Witness Name:

Signature of Witness: :

Tel. No:

Date:

Disclaimer:

All premium payments are to be paid directly to Heirs Insurance Ltd UBA Account Number 101931795. Please do not pay cash to any of our representatives as they are not authorised to receive cash.