SAVINGS INSURANCE PLAN Creditstar Microinsurance

IMPORTANT INFORMATION

THE LIABILITY OF THE COMPANY DOES NOT COMMENCE UNTIL THIS APPLICATION IS ACCEPTED AND THE PREMIUM IS PAID IN ACCORDANCE WITH SECTION 50(1) OF THE INSURANCE ACT 2003.

Kindly complete the proposal form carefully and tick where appropriate. Attach means of Identification. If our Living Benefits Advisors or any other person who assists you in completing this proposal form, such person is deemed to have done so as your Agent.

This is an investment-linked life policy designed for individuals and groups, for the accumulation of funds for a specific future need through daily, weekly, monthly, or annual contributions. Life Insurance coverage is also part of the plan.

PROPOSER’S PERSONAL INFORMATION

Title:

Eamil

Mobile Number

Surname

First name

Other names

Residentail Address

Town/City

L.G.A

Date of Birth

Occupation

Gender

Marital Status

Means of Identification:

Upload Proof of ID

Date of Issuance:

Expiry Date:

ID Number

(a) Do you have any known medical challenges?:

If yes, state the type of sickness

Emplyment Status

Name of Business/Employer

Business/Employer Address

Phone number

For Coop Society/Clubs: Name of Coop/Club:

Members Number:

Next of Kin:

Phone No:

Next of Kin Address::

Relationship with Next of Kin:

NOTE: Where Beneficiary is a Minor (less than Age 18 on last birthday), please provide details of Guardian/Legal Representative.

Name:

Email:

Phone Number:

RISK DETAILS

Sum Assured/Target Amount:

Premium/Contribution:

Policy Duration:

Minimum Contribution: ₦1,000 Others: ₦

Proposal Commencement Date

Frequency of payment:

Mode of payment:

DECLARATION

I hereby declare that the information provided by me is accurate and true to the best of my knowledge.

Signature:

Date:

IMPORTANT INFORMATION

PROPOSER’S PERSONAL INFORMATION

RISK DETAILS

DECLARATION

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