KYP 1 Bio Data 2 Beneficiary Information & Medical & Family History 3 File Upload 4 KYP TitleMr.Mrs.Miss. Name First Name Other Name (s) Emailemail Phone Number Agent Code Pick an Insurance ProductSelect An Option3 Payment PlanChildren Education PlanTarget Savings PlanUniversal Life Assurance Plan (CULAP)flexi 3 PlanMortgage Assurance PlanI-Care PlanProtection PlanCredit Life Assurance Plan Duration of Insurance CoverSelect An Option345678910111213141516171819202122232425 Date of Birthdate_range GenderSelect An OptionMale Female Marital StatusSelect An OptionMarriedDivorcedWidowed Single Home Address Office Address NationalitySelect An OptionNigeriaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongoCosta RicaCôte d’IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Place of Birth Occupation ReligionSelect An OptionChristianity IslamTraditionalOthers Source of FundSelect An OptionSalaryBusinessOthers Bank NameSelect An OptionAccess Bank PlcCitibank Nigeria LimitedEcobank Nigeria PlcFidelity Bank PlcFIRST BANK NIGERIA LIMITEDFirst City Monument Bank PlcGuaranty Trust Bank PlcKey Stone BankPolaris BankStanbic IBTC Bank Ltd.Standard Chartered Bank Nigeria Ltd.Sterling Bank PlcSunTrust Bank Nigeria LimitedUnion Bank of Nigeria PlcUnited Bank For Africa PlcUnity Bank PlcWema Bank PlcZenith Bank PlcHeritage Banking Company Ltd.Providus BankTitan Trust Bank LtdGlobus Bank Limited Do you have a life assurance policy/policiesSelect An OptionYesNo With Capital Express Assurance?Select An OptionYesNo Policy Has any proposal on your live ever been declined, postponed, deferred, withdraw or accepted on special terms?YesNo Sum Assured on active policy Hospital Name Hospital Address Beneficiary Relationship/Present AgeSelect An OptionWifeHusbandSonDaughterBrotherSisterFatherMother Years Benefit Proportion100%10%20%30%40%50%60%70%80%90%100% Other Beneficiary Relationship/Present AgeSelect An OptionWifeHusbandSonDaughterBrotherSisterFatherMother Years Benefit Proportion100%10%20%30%40%50%60%70%80%90%100% Other Beneficiary Relationship/Present AgeSelect An OptionWifeHusbandSonDaughterBrotherSisterFatherMother Years Benefit Proportion100%10%20%30%40%50%60%70%80%90%100% Height(m) Weight(Kg) What is your general state of health0 / Please state YES or NO (if Yes give details) Have you consulted any doctor or chemist within the last 5 yearsyes No Have you smoked cigarette or used narcoticsyes No Have you suffered or are you suffering from?Tuberculosis EpilepsyInsanityDiabetesOtherNo Are you PregnantYesNo If female, Maiden Name0 / If yes, what is the expected Month of delivery? What serious medical complaint have you had in your life?0 / Unexplainable, recurrent or persistent fever or skin disoder?YesNo Unexplainable, persistent night sweat?YesNo Unexplainable, weight loss?YesNo Hepatitis B or Sexually Transmitted disease, including genital sore or discharge?YesNo Unexplainable infection or swollen glands?YesNo Chronic or recurrent diarrhea?YesNo Do you intend to reside outside Nigeria?YesNo Are you HIV positive or suffering from AIDS?YesNo Have you received blood transfusion within the last five years?YesNo What games, sports or pastime do you engage in? family HistoryRelationshipAge if AlivePresent state of HealthAge of Deathprecise cause of Dealth×+ Add Row(1) Proof of addressUtility BillWater BillWaste BillStatement of account Drop a file here or click to uploadMaximum upload size: 1MBcloud_uploadUpload Upload Passport PhotografhMaximum of 1MBcloud_uploadUpload Means of identificationMeans of IdentificationInternational passportNational ID cardVoter’s cardDriver’s License Signature(Sign Here)Clear Signature Signature(Sign Here)Clear Signature Know Your Policy Branch/Agency Name Mother’s Maiden Name Employer’s Name Proof of address to be provided by Applicants (Office or Residential)Select An OptionLatest Utility BillWater BillTelephone BillBank account StatementTenancy AgreementRegistered Lease/Sale Agreement of residenceLetter from a top Civil Servant from Chairman of your LGA Source of Fund Reason for taking policy Gross Annual Income DetailsUp to N5, 000, 000Up to ₦5,000,000₦5,000,001 – ₦10,000,000₦10,000,001 – ₦15,000,000₦15,000,001 and above Occupation DetailsPrivate Sector ServicePublic Sector / Government ServiceBusiness ProfessionalAgriculturalistRetiredHousewifeStudentForex DealerOther Please Tick as applicablePolitically Exposed Person (PEP)Related to a Politically Exposed Person (RPEP)Not Politically Exposed or Related to a Politically Exposed Person Customer Signature(Sign Here)Clear Signature Customer Signature(Sign Here)Clear Signature Datedate_range Policy Submit Form keyboard_arrow_leftPrevious Nextkeyboard_arrow_right