GROUP 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)

Name of Proposer:

RC NO:

Date of Incorporation:

Address:

Nature of Affiliation (e.g social, business, etc.):

Business Description:

Phone No (Office):

Phone No. 2:

Number of Members Proposed:

Email Address:

Website:

Name of Auditors:

Address of Auditors:

Name of Bankers:

Address of Bankers:

Names of Directors:

Proposed Period of Insurance:

Total Annual Benefit:

MEMBERSHIP DETAILS

Please supply the comprehensive list of all the members to be covered.

KYC DOCUMENTS (Required Documents for Identification)

A) Certificate of Incorporation/Registration

B) Memorandum/Article of Association

C) Form CO2

D) Form CO7

E) Operating License

F) Others

DETAILS OF CONTACT PERSON

Full Name:

Address:

Email Address

Phone Number:

Designation:

OTHER INFORMATION

Are there any Additional Facts Affecting the Risk of Assurance on Your Life of which the Company should be Made Aware?

Yes

If Yes, Give Details

DECLARATION:

We, do hereby declare that our members are at present in good health and that the statements in this proposal are true and complete. We consent to Heirs Life Assurance Limited (the Company) seeking medical evidence from any doctor who at any time has attended to any of our members and/or seeking information from any insurance company to which we have at any time made a proposal for life assurance and we authorize the release of such information.

We 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 us and the Company.

Name of Authorised Officer:

Signature of Life to be Assured:

Date:

Witness Name:

Signature of Witness:

Tel No.:

Date:

DETAILS OF COMPANY REPRESENTATIVE/BROKER:

Company Representative/Broker Number:

Full Name:

Branch:

Code:

Signature:

Date: