HEIRS HOSPITAL CASH PLAN PROPOSAL 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.
Please answer ALL questions in full. Use CAPITAL LETTERS.

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:

Marital Status:

Single

Married

Name of Spouse:

Religion:

Mobile Number:

Residential Address:

Contact Address (if different from residential address):

Landmark Close to Your Place of Residence (Market, Bus Stop, etc):

Upload Utility Bill:

Driver's License:

Voter's Card:

International Passport:

National ID:

Others (Specify):

ID Number:

Issue Date:

Expiry Date:

BANK ACCOUNT DETAILS

Please Upload Passport Photograph:

Account Number:

Bank Verification Number (BVN):

Type of Employment:

Employee

Self Employed

Name of Employer:

Address of Employer

Date Employed

Tel No. of Employer:

Email Address of Employer:

WHAT IS YOUR PRESENT:

Height (Metre):

Weight:

Sports Engagement:

Do you have any pre-existing medical condition requiring hospitalization? Yes No

Have you had Heart Condition, a Stroke, Hypertension, Paralysis, Cancer, Diabetes, Kidney Failure, Liver Failure, Mental Illness, HIV Infection, or AIDS? Yes No

Do you currently have, or are you receiving treatment for any Symptoms, Medical Conditions or Disabilities? Yes No

Are you currently undergoing, or do you intend to receive treatments for cosmetic treatments, plastic surgery, refractive error
corrective procedures, experimental, investigational, or unproven procedures or treatments? Yes No

Are you currently pregnant?(for females only) Yes No

If Yes, when is your Expected Date of Delivery?

Do you smoke, drink alcohol, or take any medicines regularly? (e.g stimulants, antibiotics, sedatives, etc.) Yes No

Do you have intentions or expectations of engaging in aviation (other than as a fare-paying passenger)? Yes No

If Yes to either, Give details:

Commencement Date:

Duration of Cover (Years):

Sum Assured (#):

Premium (#):

How did you pay?

Cash

Cheque

Transfer

Amount

Date of Payment

Please attach proof of payment Number

Select the Premium Band PAID for:

Basic - 600

Intermediate 1,500

Advance - 2,800

EXISTING LIFE INSURANCE POLICIES

Please Give Details of Your Existing Life Insurance Policies Below:

Name of Insurance Company

Policy Number

Sum Assured

Please attach Details of your other life policies if more than one:

Has any Proposal on Your Life ever been Declined, Postponed, Deferred, Withdrawn, or Accepted on Special Terms? Yes No

If Yes, please Give Details:

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.) Upload Passportphoto

2.) Upload Passportphoto

3.) Upload Passportphoto

4.) Upload Passportphoto

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

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.