GROUP LIFE 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”.

The liability of Heirs Life Assurance Limited does not commence until this application is accepted and the premium is paid in accordance with section 50 (1) of Insurance Act 2003.

Name of Employer/Proposer(*):

RC number(*)

Date of Incorporation(*)

Address(*):

Type of Business(*):

Phone numbers (office)(*)

Number of Members/employees Proposed(*):

Name of Contact Person(*):

Phone number(s) of Contact Person(*)

Corporate Email(*):

Proposed Period of Insurance(*):

Total annual Emolument(*):

Proposed Benefit Per Member (i.e. Multiples of Total Emolument):(*):

Click here to download the members' schedule for upload
Upload members infomation(*):

Commencement Date of Scheme(*):

DECLARATION:

I/We, the proposer, declare that to the best of my/our knowledge and belief the information supplied in this proposal form is true, correct and complete in every detail; and shall form the basis of the contract between ..... and Heirs Life Assurance Limited.

Name of Authorized Signatory :

Position of authorized Signatory :

Authorized Signature and Stamp

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.