PROPOSAL FORM FOR STATUTORY GROUP INSURANCE

In accordance with Section 4 (5) of Pension Reform Act 2014

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.

The liability of Heirs Life Assurance Limited does not commence until this application is accepted and the premium is paid in accordance with Section 50 (1) of Insurance Act 2003.

Name of Employer/Proposer:

RC Number:

Date of Incorporation:

Address:

Type of Business:

Phone Number (Office):

Phone Number (Office 2):

Name of Contact Person:

Number of Members/Employees Proposed:

Phone Number of Contact Person 1:

Phone Number of Contact Person 2:

Corporate Email Address

Proposed Period of Insurance

Total Annual Emolument

Proposed Benefit Per Member (i.e. Multiples of Total Emolument):

Commencement Date of Scheme:

DECLARATION:

I/We, the proposer, declare that to the best of my/our knowledge and belief the information supplied in this proposal form is true, correct and complete in every detail; and shall form the basis of the contract between and Heirs Life Assurance Limited.

Dated this:

Name of Authorized Signatory:

Position of Authorized Signatory:

Authorized Signature and Stamp:

Date: