CREDIT LIFE PROPOSAL FORM

POLICY HOLDER

NAME OF PROPOSER:

Surname:

First Name:

Middle Name:

Title(Mr/Mrs/Ms/Others):

Date of Birth:

Occupation:

Gender:

Male:

Female:

CONTACT INFORMATION

Contact Address:

Email Address:

Tel. No:

PAYMENT OPTIONS

Total Loan Collected:

Premium Due:

INSURANCE BENEFICIARY/NEXT OF KIN

Surname:

First Name:

Middle Name:

Title(Mr/Mrs/Ms/Others):

Date of Birth:

Occupation:

Gender:

Male:

Female:

Relationship:

Contact Address:

DECLARATION

I agree that this application is subject to policy terms and conditions. I understand that the information provided by me and any documents required by the Company shall be the basis of the policy. I declare that all the information provided by me, whether in my own handwriting or not, is true and complete. I accept that I am curtailing my right to privacy to facilitate the assessment of the risk and of any claims for benefits under any policy issued in respect of this application.

I irrevocably authorise:

1. The Company to obtain from any person, whom I hereby so authorise and request to give, any information which the Company deems necessary, and to share with other insurers that information and any information contained in this application or in any related policy or other document.

2. I acknowledge receipt of the policy terms and conditions associated with policy application.

3. I acknowledge that I have read and understood these declarations.

Customer Signature:

Date:

Heirs Life Assurance Signature:

Date: