Untitled Document
Google
  Bancassurance Login
Username:
Untitled Document
Home » Commercial Insurance » Quotes and Forms » Forms
  PROPOSAL FOR IDA INVESTMENT LINKED POLICY  
     
 

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

1.
(a)  Proposer
Agent Individual
  TITLE  
  Surname *  
  First Name *  
  Other Names  
  NEE (if a married woman)  
         
(b) Full Postal Address *
(to which all correspondence would be sent)		  
  Tel. No. *  
         
  Permanent Address  
  Tel. No.  
         
(c) Occupation
(Pls give full details)		  
  Fax. No.  
  E-mail Address *  
         
(d) Date of Birth
Day   Month  Year
 
         
(e) Nationality  
         
(f) Marital Status
Married Single Divorced Widow
 
         
2.
(a)
i Premium Payable
(in Naira)		 Annually Bi-Annually Quarterly Monthly
     
ii
Mode of Premium Payment Cheque Draft Banker's Order Direct Debit
 
(b)
i
Date of payment of first premium Day Month Year
ii
Amount of Deposit Receipt No.
iii
Proposed date of assurance
 Day   Month  Year
iv Duration
(c)
i
If for child's education. Name of Child.
Surname
First Name
Middle Name
Sex
ii
Date of birth
 Day  Month  Year
3.
(a) Name of your Usual Medical Doctor
  Address of Medical Doctor
(b) Please give details of treatments you have received in the last 5 years and dates.
4.
(a)
Height (in meters) Weight (in kilograms)
(b)
What is your daily consumption of
Alcohol (Beer, Wine, Spirit)
Tobacco (cigarette, snuff)
Narcotics
(c)
If female, are you pregnant now?
If yes, Expected Date of Delivery
5.
Have you ever been treated for or suffered from :
(a) Epilepsy or other mental disturbances?
(b) Tuberculosis, Asthma, Pneumonia or any other chest disease?
(c) Indigestion, Gastric or duodenal ulceration, Jaundice, Gall-bladder?
(d) Nervous disease or Nervous Breakdown, Frequent Headaches?
(e) Any infection of the Kidney, Urinary or Genital Organs, Renal Stones, Difficult or Painful Urination, Blood in Urine?
6.
(a)
Have you ever had:
i Recurrent or Persistent Fever Skin Disorder?
ii Persistent Night Sweat?
iii Weight Loss?
iv Glandular Infection or Swollen Glands?
v Chronic or Frequent Diarrhoea?
vi Persistent Cough?
vii Hepatitis B or any sexually transmitted disease including genital sores or discharges?
(b) Have you ever been refused as a blood donor?
(c) Have you ever received any blood transfusions within the last five years?
7.
Have you ever:
(a) Undergone any surgical operation?
(b) Had an X-ray of the chest, stomach or any other organ?
(c) Had an Electrocardiogram (ECG), Blood Studies or other special investigations or tests not mentioned above?
8. OTHER ASSURANCES ON YOUR LIFE
 
(a)
Has any proposal on your life ever been made to LEADWAY or any Insurance Company?
  If Yes, please give details of Sum Assured
  Policy No.
  Insurance Company
(b) Was it accepted on normal terms, special terms, postponed or declined?
   
9.
Name of beneficiary (ies)
Relationship
Next of Kin
Relationship
I agree with all the terms and conditions. click here to read terms and conditions.

Follow this link to go back the page you were previously looking at.
Untitled Document
Copyright 2007 Leadway Assurance Company Limited. | Web Mail All rights reserved.