Quality Investment Plan Proposal Form "*" indicates required fields 1Personal 2Employment Details3Policy Details4Medical History5Supplementary Details PERSONAL DETAILSPolicyholder Full name* Date of Birth* DD MM YYYY Age Next BirthdayGender* Male Female Marital Status* Single Married Separated Widowed Contact DetailsPhone number*MobileEmail Address* Address* Street Address Address Line2 Address Line 2 Are you a Resident?* Yes No Country of origin* City AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please indicate Country of origin EMPLOYMENT DETAILSIndustryAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherOccupation* Staff Number ID Number Unit Number Employer's Name* Telephone*MobileEmployer's Address* Street Address Address line 2 Address Line 2 POLICY DETAILSSum Assured (GHS)Standard Premium(GHS)Extra Premium(GHS)Contribution Frequency* Monthly Quarterly Semi-Annually Annually Mode of Payment* Accountant General Company Payroll Cheque Bank Insurance History1. Do You Have Any Insurance On Your Life? (If YES, Provide Company Name)* Yes No Assurer Name 2. Have you ever been refused Life Assurance, your Application Deferred or had Special Terms Imposed on it? If so, when any, by which Company?* Yes No Application deferral details Beneficiaries & TrusteesBENEFICIARIES*Beneficiary Full NameAgeRelationshipAddress Add RemoveTRUSTEES*Trustee Full NameAgeRelationshipAddress Add Remove MEDICAL HISTORYName of Medical Attendant (Doctor or Hospital)* Your Medical Attendant Name For how long does he/she know you?* Number of days, weeks, yearsWhen did you last consult him/her? Reason.* Last visit and reasonMedical Attendant Address* Street Address Address Line 2 Address Line 2 Your weight*Weight unit*KgLbWeight Status* Decreasing Increasing Stationary Your Height*Height unit*cminchesHave you ever suffered or do you suffer from?a) Sickle Cell disease, Hypertension, Heart disease, Stroke, Goiter or Rheumatism* Yes No a) Sickle Cell disease, Hypertension, Heart disease, Stroke, Goiter or Rheumatism (Details)* b) Albumen, Blood or Sugar in Urine, Diabetes or Epilepsy?* Yes No b) Albumen, Blood or Sugar in Urine, Diabetes or Epilepsy? (Details)* c) Kidney stone, Colic Bladder trouble, or any other Genito-urinary disorder?* Yes No c) Kidney stone, Colic Bladder trouble, or any other Genito-urinary disorder? (Details)* d) Any trouble, not mentioned above or X-ray, or nay special investigation?* Yes No d) Any trouble, not mentioned above or X-ray, or nay special investigation? (Details)* e) Have you had any Illness, Surgical Operation Met with any Accident or undergone any Special Investigation?* Yes No e) Have you had any Illness, Surgical Operation Met with any Accident or undergone any Special Investigation? (Details)* f) Have you ever been advised in connection with AIDS or any Sexually Transmitted Disease?* Yes No f) Have you ever been advised in connection with AIDS or any Sexually Transmitted Disease? (Details)* DECLARATION* I declare that to the best of my knowledge and belief that all the above statements are true and I agree that they together with any statements made to a medical examiner, shall be the basis of contract between me and the Company to which I have made a proposal for the Life Assurance.Post ImageAccepted file types: jpg, jpeg, png, gif.SignatureDate* DD MM YYYY Witness DetailsFull names* Phone/MobileAddress* Witness signature Date* DD MM YYYY Witness SignaturePhoneThis field is for validation purposes and should be left unchanged.
