Quality Mortgage Protection Proposal Form "*" indicates required fields 1Personal 2Employment3Policy 4Medical 5Supplementary Details6Family Records7Submit PERSONAL DETAILSProvide answers to all enquiries belowPolicyholder Full name*Date of Birth* DD MM YYYY Age Next BirthdayYearsPlace of Birth*Gender* Male Female Marital Status* Single Married Separated Widowed Contact DetailsMobile*Phone numberEmail Address* Address* Street Address Address Line 2 Address Line 2 Are you a Resident?* Yes No City/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 EMPLOYMENT DETAILSProvide answers to all enquiries belowIndustryAccounting/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 NumberID NumberUnit NumberEmployer's Name*Telephone*MobileEmployer's Address* Street Address Address line 2 Address Line 2 PROPOSED SUM ASSURED AND POLICY DETAILSProvide answers to all enquiries belowProposal Sum AssuredClass of AssuranceTerm of Assurance (years)*If child education, indicate number of years benefit is payable* Yes No Benefit Payable (Years)*Do You Have Any Assurance On Your Life? If so, State Companies and Amounts.* Yes No Company NameAmount involved* MEDICAL HISTORYProvide answers to all enquiries below1. Do you suffer or have suffered from any illness, Accident, Physical or Mental Disability or Undergone Surgical operation? If so, give details* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*2. a) Nervous breakdown, fit overwork, Anaemia, Nervous or Mental Disorder?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*2. b) Pleurisy, Tuberculosis, or lung Disorder?* Yes No Doctor or Hospital name*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*2. c) Sickle cell disease, hypertension, heart disease, apoplexy, goitre, or rheumatism?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*2. d) Albumen, blood or sugar in the urine?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*2. e) Ulcer, intestinal, liver or billary disease or any abdominal disorder?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*2. f) Kidney stone, colic, bladder trouble or any other genito-urinary disorder?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*2. g) Yaws, leprosy, syphilis, malaria, gonorrhea, biharzia, onchocerchiacis, and trypanosomiasis?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*2. h) Hernia, varcose veins, physical deformity, injury or any ailment?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*2. i) Any trouble, not mentioned above, or X-ray, or any other special investigation?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*3. Have you ever been refused as a Blood donor?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*4. Have you ever received Blood Transfusion within the last five (5) years?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*5. Have you ever had:5. a) Unexplained recurrent or persistent fever or skin Disorder?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*5. b) Unexplained infection or swollen glands?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*5. c) Unexplained infection or weight loss?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*5. d) Chronic or recurrent diarrhea?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*5. e) Persistent Cough?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*5. f) Hepatitis B or Sexually transmitted diseases including genital sore?* Yes No Disease or Injury Details*Date* MM slash DD slash YYYY Duration*Result*Doctor or Hospital name*6) Have you ever had or been advised to have a blood test for AIDS or an AIDS condition?* Yes No 7) Have you ever been refused Life Assurance?* Yes No Name of the Company* FOR FEMALE DETAILS ONLYTick option and fill this supplementary section if policyholder is a female, else live and click "Next"Female Yes 8. a) Have you suffered from any female disease?* Yes No Disease Details8. b) Are you pregnant?* Yes No 8. c) How many of your Children are alive?*8. d) How many of your children are dead?*8. e) What is your Height? (m)*8. f) What is your Weight? (Kg) (lb)*8. g) What is Your Average Daily Consumption of Alcohol?*8. h) How much do you smoke daily?*8. i) Have You Ever Resided in Any Mining Area in West Africa? (If so, Where and how long?)* Yes No Location and duration*8. h) Are You In Good Health?* Yes No What illness are you suffering from?* 9. FAMILY RECORDSChoose from the family member option and fill in the corresponding details.Father Living Non-Living Mother Living Non-Living Father's Age*Father's Heath*Mother's Age*Mother's Health*Father's Age at Death*Cause of Death*Mother's Age at Death*Cause of Death*Living Siblings Sisters Brothers Non-living Siblings Sisters Brothers Living Brother's Details*Brother's AgeBrother's Health Add RemoveClick "+" sign to add other living brothers Living Sister's Details*Sister's AgeSister's Health Add RemoveClick "+" sign to add other living sistersNon-living Brothers' Details*AgeCause of Death Add RemoveClick "+" sign to add other non living brothers Non-living Sisters' Details*AgeCause of Death Add RemoveClick "+" sign to add other non-living sisters10. Has any member of your family ever had:10. a) Any heart Ailment?* Yes No 10. b) Diabetes?* Yes No 10. c) Stroke?* Yes No 10. d) Tuberculosis?* Yes No 10. e) Insanity* Yes No BENEFICIARIES*NamesAgeRelationshipAddress Add RemoveClick "+" sign to add more beneficiaries DECLARATION & SUBMISSIONEnter family records hereDECLARATION* 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.Your passport photographAccepted file types: jpg, jpeg, png, gif.Upload your ID Card here* Drop files here or Select files Max. file size: 512 MB. Upload the front and the back of your Identification card hereSignatureDate* DD MM YYYY Witness DetailsFull names*Phone/MobileAddress*Witness signature Date* DD MM YYYY Witness SignatureCommentsThis field is for validation purposes and should be left unchanged.
