IMPORTANT
An Insurance Agent who assists an applicant to complete an 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.Please answer ALL questions in full. Use CAPITAL LETTERS.
Name:
Title:
Home Address:
Office Address:
Home Telephone:
Office Telephone:
Email:
Date of Birth:
Gender: MaleFemale
Religion:
Nationality:
State:
L.G.A.:
Town:
Profession/Occupation:
Designation:
Type of Employment:
EmployeeSelf Employed
If Employee, Name of Employer:
Address of Employer:
Date of Employment:
Employer's Tel. No.:
Marital Status: MarriedSingleDivorcedSeparated
Please if married, give the following:
Name of Spouse:
Wedding Anniversary:
Spouse Date of Birth:
Next of Kin:
Type of Residence: OwnerTenant
Documents to be Submitted:
Electricity Bill:
Any of the following Personal Identification Cards: Driver's LicenseNational IDInternational Passport
Upload Personal Identification Cards:
Social & Political Activities:
Which Social/Membership club do you belong:
Do you or your spouse belong to any political or pressure group? YesNo
Does any of your close relations belong to any political or pressure group? YesNo
FatherMotherUncleIn-LawWifeHusbandBrotherSister
I consent that my personal information can be used in line with Heirs Insurance Data Policy. See details of the policy.
Customer's Signature:
Date:
Δ
