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LIFE ASSURANCE PROPOSAL FORM

An Insurance Agent who assists an applicant to complete an application or porposal form for insurance shall be deemed to have done so as the Agent of the Applicant.

Please Note:-
  1. The company is only bound by document bearing the signature of the Executive Vice Chairman or a person authorised to sign on his behalf.

  2. The company shall not be on risk until the proposal has been accepted in writing and the first premium received in full.
Please complete in BLOCK LETTERS. Do not put a "DASH"
1. LIFE PROPOSED
Surname
Forenames
Marital Status
Permanent Home Address
Local Govt. Area
State
Telephone No.
Residential Address (If different from above)
Local Govt. Area
State
Telephone No.
Correspondence Address
Name of Employer
Address of Employer
Telephone No.
Occupation (Actual Nature)
Name and Address of Bankers
name
address
Date of Birth
Age Next Birthday
Place of Birth
 
BENEFICIARY (Print) include address if other than as above
Full Name (and Address) Age Relationship
 
PROPOSAL FOR EDUCATIONAL ASSURANCE ONLY
1. THE CHILD
Surname
Christian or Forenames
Sex
Date of Birth
Place of Birth
Relationship to Child
 
2. EXISTING POLICIES
Other Life Assurance Policies in force
Policy Number Date of Issue Name of Company Amount
   
3. THE POLICY
Type of Assurance
With/Without Profit
Sum to be Assured
Interest Rate (If Mortgage Protection)
Period of Assurance
Name of Lender (If Mortgage Protection)
   
DO YOU DESIRE ANY ADDITIONAL BENEFIT?
(a)  Double Indemnity
(b)  Personal Accident Indemnity
(c)  Disability Waiver of Premium
(d)  Family Income Benefit
Permium Payable (per annum)
How are future premiums to be paid? 
   
4. PERSONAL QUESTIONNAIRE
In order that full consideration be given to this proposal the following question must be answered by the life to be Assured. Dashes are not accepted.
(a) Is life proposed in good health
If the answer is YES please give full details with dates
(b) Has any life or health insurance proposal on your life been declined, postponed or accepted on special term?
If the answer is YES please give full details with dates
(c) Are you likely to: (i)Fly other than as a fare-paying Passenger
If the answer is YES please give full details with dates
(ii)  Engage in any dangerous Occupation or activity?
If the answer is YES please give full details with dates
(iii)  Change your occupation
If the answer is YES please give full details with dates
(d) Do you drink alcohol?
Average daily consumption
(e) Do you smoke cigarette?
Number smoked daily
(ii) If the answer is NO, have you smoked cigarette in the last 12 months?
If the answer is YES, please, give full details with dates
(f)  Have either of your parents, brothers or sister died?  
Relationship 
Age at death
Cause of death
(g) Do you have one wife?
If the answer is YES, please, give names of the wives
(ii) Have you during the last five years suffered from any illness, accident or disease requiring medical attention or undergone any medical investigation?

If the answer is YES, please, give full details with dates
(j)  Have you suffered from any illness, accident or disease more than five years ago which lasted for more than one month? (Details of any hereditary disease or any disability should be included)

  

If the answer is YES, please, give full details with dates
If the answer is YES, please, give full details with dates
(k)  Name and address of your doctor (past or present)
(l)  Have you ever had
  • Recurrent or persistent fever or skin disorder?
  • Persistent night sweat?
  • Weight loss
  • Infections or swollen glands?
  • Chronic or frequent diarrhea?
  • Persistent cough?
  • Hepatitis b o rany sexually transmitted disease including genital sores or discharge?
  • Have you received any blood donor?
  • Have you received any blood transfusions within the last five years?
Please give full details of all positive answers
(m) Give details of your height and weight ft/ Meter.
Kgs/ibs
(n) FOR FEMALES ONLY:  
To your knowledge are you pregnant?
If Yes how many months.
   
DECLARATION
   
I hereby declare that to the best of my knowledge and belief the answers given in this proposal are true and complete. I consent to Guardian Trust Insurance Company Limited seeking medical information from any doctor who at any time has attended to me concerning anything which affects my physical or mental health or seeking any information from any insurance office which a proposal has been made for insurance on my life and I authorise the giving of such information. I agree that the answers given together with those made to a medical examiner, if a medical examination should be required, shall be the basis of the proposed contractof assurance. I confirm that I have read over all answers completed by me in my own handwriting and that they are correct.
Signature of Life to be Assured Date
Signature of witness Date
When is the policy to commence?
   
Name
Distict
Unit Number
Code Number
Date
 

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