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HEIRS GROUP SAVE PROPOSAL/KYC FORM
IMPORTANT INFORMATION
An insurance agent who assists an applicant to complete an application or proposal or KYC form for insurance shall be deemed to have done so as an agent of the applicant in accordance with section 54 (2) of Insurance Act 2003.
DETAILS OF THE PERSON TO BE INSURED (Person to be covered by the insurance policy)
Surname:
First Name:
Middle Name:
Title (Mr/Mrs/Ms/Others):
Maiden Name (if applicable):
Date of Birth:
Gender:
Male
Female
Place of Birth
Nationality:
State of Origin:
Local Government of Origin:
Marital Status:
Single
Married
Name of Spouse:
Religion:
Occupation:
Designation:
Email Address:
Mobile Number:
Telephone Number.:
Residential Address:
Contact Address (if different from residential address):
Landmark Close to Your Place of Residence (e.g Police Station, Market Place, Bus Stop, etc):
IDENTIFICATION
Driver's License:
Voter's Card:
International Passport:
National ID:
Others (Specify):
ID Number:
Issue Date:
Expiry Date:
Please Upload Passport Photograph:
BANK ACCOUNT DETAILS
Bank Name:
Bank Branch:
Account Number:
Bank Verification Number (BVN):
OCCUPATION
Type of Employment:
Employee
Self Employed
Name of Employer:
Address of Employer
Date Employed
Tel No. of Employer:
Email Address of Employer:
Annual Income Band:
Below #5 Million
#5 - 10 Million
Over #10 Million:
DETAILS OF COVER
Name of the Heirs Life Assurance Product You Want to Buy:
Commencement Date:
Investment Period (Years):
Preferred Amount of Life Cover (#):
Proposed Annual Contribution (#):
Frequency of Premium Payment:
Single
Monthly
Quarterly
Semi-annually
Yearly
Preferred Mode of Payment:
*Automatic Salary Deduction
Fund Transfer
Cheque
**Direct Debit
*Please complete the Salary Deduction Mandate. **Please complete the Direct Debit Mandate.
DEPOSITS MADE WITH THIS PROPOSAL (OPTIONAL)
Cash
Cheque
Transfer
Amount
Date of Payment
Receipt of Payment
BENEFICIARY(IES) DETAILS (PASSPORT PHOTOGRAPH REQUIRED)
1. Name of Beneficiary
Mobile Number
Email Address
Relationship
% Share
2. Name of Beneficiary
Mobile Number
Email Address
Relationship
% Share
3. Name of Beneficiary
Mobile Number
Email Address
Relationship
% Share
4. Name of Beneficiary
Mobile Number
Email Address
Relationship
% Share
1. Passport
2. Passport
3. Passport
OTHER INFORMATION
Are there any Additional Facts Affecting the Risk of Assurance on Your Life of which the Company should be Made Aware?
Yes
No
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 Limited (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.
Signature of Life to be Assured:
Date:
Witness Name:
Signature of Witness:
Tel No.:
Date:
DETAILS OF COMPANY REPRESENTATIVE/BROKER:
Full Name:
Branch:
Code:
Signature:
Date:
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