Quality Smart Plan Proposal Form "*" indicates required fields 1Personal 2Employment3Policy 4Medical 5Supplementary Details6Family Records PERSONAL DETAILSProvide answers to all enquiries belowPolicyholder Full name* Date of Birth* DD MM YYYY Age Next BirthdayPlace of Birth* Gender* Male Female Marital Status* Single Married Separated Widowed Contact DetailsPhone number*MobileEmail Address* Address* Street Address Address Line 2* Address Line 2 Are you a Resident?* Yes No Indicate your Country of origin if “Yes” 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 Number ID Number Unit Number Employer's Name* Telephone*MobileEmployer's Address* Street Address Address line 2 Address Line 2 COVER DETAILSProvide answers to all enquiries belowInitial Sum AssuredBasic Premium*Premium For RiderTOTAL PREMIUMPAYMENT DETAILSPayment Frequency* Monthly Quarterly Semi-Annually Annually Mode of Payment* Accountant General Company Payroll Cheque Bank Please attach a completed mandate form if you are not paying by cash/cheque)Term of Assurance* Two (2) Years Three (3) Years Four (4) Years Five (5) Years Six (6) Years Seven (7) Years Eight (8) Nine (9) Years Ten (10) Years Auto Inflation Adjuster Rate* 0% 10% 12.5% 15% Do you require Total and Permanent Disability Benefit* Yes No MEDICAL HISTORYProvide answers to all enquiries below1. Your Medical Attendant Name* 2. Medical Attendant Address* 3. For how long does he/she know you?* 4. When did you last consult him/her? and the reason.* 5. What is your weight?* Is your weight within the last twelve (12) years* Decreasing Increasing Stationary What is you Height?* 6. Are You in Good Health?* Yes No 7. Are you currently on any medication for the past (12) twelve months?* Yes No Disease or Injury Details* Date* MM slash DD slash YYYY Duration* Result* Doctor or Hospital name* 8. Do you have or have you ever had any of the following:8. a) Asthma, Persistent cough, Blood spitting, Chest pains, Tuberculosis, Pneumonia Hypertension?* Yes No Disease or Injury Details* Date* MM slash DD slash YYYY Duration* Result* Doctor or Hospital name* 8. b) Sickle cell disease, Stroke, Goitre, Rheumatism, Epilepsy, Dizziness, Paralysis, Mental disorder?* Yes No Disease or Injury Details* Date* MM slash DD slash YYYY Duration* Result* Doctor or Hospital name* 8. c) Diabetes, Blood in Urine, Skin Disease, Tumor, Kidney disease?* Yes No Disease or Injury Details* Date* MM slash DD slash YYYY Duration* Result* Doctor or Hospital name* 8. d) Do you have any sexually transmitted infection or currently suffering from HIV or AIDS?* Yes No Disease or Injury Details* Date* MM slash DD slash YYYY Duration* Result* Doctor or Hospital name* 8. e) Any sickness not mentioned above or X-ray or any special investigation?* Yes No Disease or Injury Details* Date* MM slash DD slash YYYY Duration* Result* Doctor or Hospital name* 9.Have you ever had any Surgical operation or had any accident or undergone any special investigation within the last twelve (12)years?* Yes No Disease or Injury Details* Date* MM slash DD slash YYYY Duration* Result* Doctor or Hospital name* INSURANCE HISTORYEnter history here1. Do You Have Any Insurance On Your Life? (If YES, Provide Company Name)* Yes No Company 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 Refusal Details BENEFICIARIES*NamesAgeRelationshipAddress Add RemoveClick "+" sign to add more beneficiaries TRUSTEES*NamesAgeRelationshipAddress Add RemoveClick "+" sign to add more trustees DECLARATION & SUBMISSIONConfirm details and submit formDECLARATION* 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 back of your Identification card hereSignatureDate* DD MM YYYY Witness DetailsFull names* Phone/MobileAddress* Witness signature Date* DD MM YYYY Witness SignatureNameThis field is for validation purposes and should be left unchanged.