COUPLES PLAN 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:

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:

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

Upload Receipt

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

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: