1 Bio Data
2 Beneficiary Information / Medical & Family History
3 Medical History
4 Declaration / Signature
Means of Identification:

Please note that the guaranteed minimum interest on savings contribution is 2.5% per annum.

Mode of Payment:
Your preferred mode(s) of receiving information and mails from the company:
Do you have an existing Life Assurance Policy
Has any proposal on your life ever been declined, postponed, deferred, withdraw or accepted on special terms?

If Female, Maiden Name

Are you pregnant ?
Have you consulted any doctor or chemist within the last 5 years
Have you smoked cigarette or used narcotics

Have you had :

Unexplainable, persistent night sweeats and/or weight loss
Unexplainable, recurrent or persistent fever or skin disoder?
Chronic or recurrent diarrhea?
Unexplainable infection or swollen glands?
Have you received blood transfusion within the last five years?
If any other (specify)
Tuberculosis
Epilepsy
Heart Disease
Insanity

DECLARATION

I, the life to be assured, confirm that all the foregoing answers, statements, particulars and additional information are true, that I have not concealed or withheld any information or material facts that may alter the insurer’s view of the risk or affect their assessment of the exposures they are covering under the Policy and I am willing to be medically examined if required. I agree that all statements I have made in this or previous proposal(s) shall be the basis of the contract of insurance. I further agree that, this life assurance will not be in force until the proposal has been accepted and premium is paid in accordance to section 50(1) of Insurance Act, 2003. I irrevocably authorize and request any qualified medical practitioner or other person who may be in possession of, or hereafter acquire, any information concerning my health up to the present time to disclose such information to the company.

 

Signature of proposal
(Sign Here)
Clear Signature
Agent Signature
(Sign Here)
Clear Signature
Agency Manager Signature
(Sign Here)
Clear Signature

NOTICE: IT IS MANDATORY TO DEMAND FOR RECEIPT ON ALL PAYMENTS MADE, CHEQUES SHOULD BE ISSUED IN FAVOUR OF CAPITAL EXPRESS ASSURANCE LIMITED

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