ANNUITY 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.

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:

Retiree NIN No:

Marital Status:

Single:

Married:

Name of Spouse:

Religion:

Occupation:

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:

Retired:

Name of Last Employer:

Address of Last Employer

Email Address of Last Employer:

Tel No. of Last Employer:

OTHER DETAILS

Name of Pension Fund Administrator:

Address of Pension Fund Administrator:

Date of Retirement:

RSA No.:

DETAILS OF COVER

Preferred Type of Annuity:

Immediate Annuity:

Deferred Annuity:

Commencement Date for Annuity Payment:

Annuity Guaranted Period (Years):

Proposed Single Premium for Immediate Annuity (#):

Frequency of Premium Payment (for Deferred Annuity):

Preferred Mode of Premium 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:

Amount

Date of Payment

Receipt Number

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

4. Passport

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: