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    Fund Transfer

    Account Name: Heirs Life Assurance
    Account No: 1023719474
    Bank: UBA
    Attach Fund Transfer Receipt:


    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.