LIFE INSURANCE 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.

PERSONAL DETAILS OF THE PERSON TO BE INSURED

Title: (*)

Surname: (*)

First Name: (*)

Middle Name:

Email: (*)

Religion:

Gender: (*)

Marital Status:

Occupation: (*)

Mobile Number: (*)

Date of Birth: (*)

Place of Birth: (*)

State of Origin: (*)

Nationality: (*)

Residential Address: (*)

Contact Address (if different from residential address):

Identification: (*)Driver LicenseVoter CardInternational PassportNational ID

Others (Specify):

Upload Passport Photograph: (*)

Upload Valid ID Card: (*)

Proof of Address: (*)

PLAN DETAILS

Select Plan Type: (*)

Frequency of Premium Payment: (*)

Premium (N): (*)

Sum Assured (N): (*)

Plan Duration: (*)

Preferred Mode of Payment: (*)

Fund Transfer

Account Name: Heirs Life Assurance

Account No: 1023719474

Bank: UBA

Attach Fund Transfer Receipt:

Direct Debit

Please complete the Direct Debit Mandate.

Bank Account Details (For Claims Payment):

Bank Name: (*)

Account Number: (*)

Bank Verification Number (BVN): (*)

HEALTH INFORMATION

Height (Metre): (*)

Weight (Kg.): (*)

Have you had Heart Condition, a Stroke, Hypertension, Paralysis, Cancer, Diabetes, Kidney Failure, Liver Failure, Mental Illness, HIV Infection or AIDS? (*)

Do you currently have, or are you receiving treatment for any Symptoms, Medical Conditions or Disabilities? (*)

Have you been absent from work due to Illness or Injury for a continuous period of more than 10 days during the past one year? (*)

Habit

Do you smoke, drink alcohol, or take any medicines regularly? (e.g stimulants, antibiotics, sedatives etc.) (*)

If Yes to either, Give details:

Has any Proposal on Your Life ever been Declined, Postponed, Deferred, Withdrawn or Accepted on Special Terms? (*)

If Yes, please Give Details:

BENEFICIARY(IES) DETAILS (PASSPORT PHOTOGRAPH REQUIRED)

Name of Beneficiary (*)

Mobile Number (*)

Email Address (*)

Relationship (*)

% Share (*)

For more beneficiaries:

Name of Beneficiary

Mobile Number

Email Address

Relationship

% Share

Name of Beneficiary

Mobile Number

Email Address

Relationship

% Share

Name of Beneficiary

Mobile Number

Email Address

Relationship

% Share

Name of Beneficiary

Mobile Number

Email Address

Relationship

% Share

OTHER INFORMATION

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

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: (*)