3. RESIDENTIAL ADDRESS: OCCUPATION:... ADDRAESS:.. (PLEASE GIVE PRECISE DETAILS) D M Y MALE SINGLE DIVORCED
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1 Insurance Company Limited HEAD OFFICE: No. 9/1&2 Saxel Avenue, Tesano, Opposite Tesano Police Station, Accra P. O. Box AT 1975 Achimota Market, Accra, Ghana. TEL.: ( ) / Fax APPLICATION FOR LIFE ASSSURANCE A IDENTITY 1. SURNAME..... OTHER NAMES POSTAL ADDRESS.....TEL. NO.: RESIDENTIAL ADDRESS: OCCUPATION:... ADDRAESS:.. (PLEASE GIVE PRECISE DETAILS) 5. EMPLOYER S NAME AND ADDRESS.. 6. DATE OF BIRTH 7. AGE NEXT BIRTHDAY 8. SEX 9. MARITAL STATUS D M Y MALE SINGLE DIVORCED FEMALE MARRIED WIDOWED B. BENEFITS AND PREMIUM 10. PLAN OF ASSURANCE: TERM: 12. SUM ASSURED RIDERS REQUIRED: PERSONAL ACCIDENT PERMANENT DISABILITY BENEFIT 14a. PAYMENT FREQUENCY 15. BASIC PREMIUM US$/GH.. MONTHLY SEMI-ANNUALLY ADDITIONAL PREMIUM US$/GH. QUARTERLY ANNUALLY EXTRA PREMIUM US$/GH. TOTAL PREMIUM US$/ GH. 14b. MODE OF PAYMENT: Cash Cheque Standing Order Employer Deductions C. GENERAL 16. DO YOU HAVE ANY ASSURANCE ON YOUR LIFE? YES NO IF YES STATE COMPANY. AMOUNT US$/GH..... POL. No. 17. HAS ANY PROPOSAL ON YOUR LIFE EVER BEEN DECLINED, POSTPOND OR ACCEPTED WITH EXTRA PREMIUM? YES NO
2 IF YES WHEN AND WHICH COMPANY?.... YOUR STATE OF HEALTH 18. HEIGHT CM/FT. WEIGHT KG/LB. 19. Father Mother Brother Sister FAMILY HISTORY LIVING Age State Of Health Age At Death DEAD Cause Of Death 20. ARE YOU LIKELY TO ENGAGE IN ANY SPORTING ACTIVITIES OR OTHER LEISURE PURSUITS WHICH INVOLVE ADDITIONAL RISK OF DEATH BY ACCIDENT? YES NO (PLEASE GIVE DETAILS IF YOUR ANSWER IS YES). 21. HOW WOULD YOU RATE YOUR ALCOHOL CONSUMPTION? NIL MODERATE LIGHT HEAVY 22. HOW MUCH DO YOU SMOKE DAILY?. 23. ARE YOU AT PRESENT IN GOOD HEALTH? YES NO
3 24. HAVE YOU HAD ANY ILLNESS, 25. HAVE YOU EVER HAD AN 26. HAVE YOU EVER BEEN ACCIDENT OR UNDERGONE OPERATION OR ANY MEDICAL MEDICALLY ADVISED IN ANY TREATMENT IN A HOSPITAL EXAMINATION SUCH AS X RAY CONNECTION WITH AIDS OR SANATORIUM WITHIN THE ECG, BLOOD OR URINE TEST? OR ANY SEXUALLY LAST 5 YEARS? TRANSMITTED DISEASE? YES NO YES NO YES NO IF QUESTION 23 IS ANSWERED NO OR ANY OF THE QUESTIONS ABOVE IS ANSWERED YES, PLEASE GIVE DETAILS BELOW. ILLNESS OR INVESTIGATION DATE DURATION RESULTS DOCTOR S NAME AND ADDRESS 27. BENEFICIARIES OR FINANCIER (FOR MORTGAGE PROTECTION) 1. NAME AGE RELATIONSHIP % ADDRESS NAME AGE RELATIONSHIP % ADDRESS DECLARATION I DO HEREBY DECLARE THAT ALL THE ANSWERS TO THE FORGOING QUESTIONS ARE IN EVERY RESPECT TRUE AND CORRECT AND DO HEREBY AGREE THAT THIS PROPOSAL AND DECLARATION TOGETHER WITH ANY STATEMENT MADE TO A MEDICAL EXAMINAR SHALL BE THE BASIS OF THE CONTRACT BETWEEN ME AND UT LIFE INSURANCE COMPANY. I AGREE THAT ASSURANCE SHALL BE IN EFFECT ONLY WHEN A DULY SIGNED POLICY IS RECEIVED BY ME AND FIRST PREMIUM PAID IN FULL. DATED: THIS DAY OF 20.. SIGNATURE OF PROPOSER SIGNATURE OF AGENT FOR HEAD OFFICE USE D M Y ACCEPTED BY AGENT ISSUE DATE ISSUE BY NUMBER POLICY NO. APPROVED BY PLACE
4 SUPPLEMENTARY QUESTIONNAIRE FULL NAME:.. ADDRESS:. AGE: Please give full details of all positive answers: DETAILS 1. HAVE YOU EVER HAD? a) Unexplained recurrent or persistent Fever or skin disorder? b) Unexplained, persistent night sweats? c) Unexplained weights loss? d) Unexplained infections or swollen glands? e) Chronic or recurrent diarrhoea? f) Persistent cough? g) Hepatitis B or sexually transmitted diseases including genital sores or discharge? 2. HAVE YOU EVER HAD OR BEEN ADVISED TO HAVE A BLOOD TEST FOR AIDS OR AN AIDS RELATED CONDITION? 3. Have you ever been refused as a blood donor? 4. Have you received a blood transfusion within the last five (5) years? I declare that the foregoing answers are true, that I have not withhold any important circumstance or detail, and I agree that this declaration shall be held to form part of the proposal for life assurance now made to UT Life Insurance Company Limited Dated.. Signature. Witness
5 DECLARATION OF GOOD HEALTH FULL NAME:. ADDRESS:. AGE:.. With reference to my proposal dated.for a policy of assurance for US$.. on my life I hereby declare that since the date of the above proposal I have not suffered from any illness nor has my state of health changed in any way except as stated below. I agree that this declaration together with the above dated proposal shall be the basis of the proposed contract. Signed.. Date Please give full details of any illness etc., including dates, names and addresses of doctors consulted if the above declaration so requires.
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Mortgage Critical Illness Insurance Claim Creditor Insurance Policy no. 57904
Mortgage Critical Illness Insurance Claim Creditor Insurance Policy no. 57904 BMO Bank of Montreal Representative: First name Last name Branch Domicile Stamp Signature Fax number What information is required
Workman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
Application for Conversion of Group Term Life & Accidental Death Insurance Aetna Life Insurance Company
Application for Conversion of Group Term Life & Accidental Death Insurance Aetna Life Insurance Company Application and payment of the first premium must be made within the time limit shown in your certificate
FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA
PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
Application for residence permit for the purpose of study
Application for residence for the purpose of study _ _ _ _ _ _ _ _ _ _ number: Authority receiving the application: File Office recording the data included in the application: Residence issued for the
Claim for Compensation for a Work-related death
SRC184(Feb2008) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) for the