Proposal/Application Form

Salary-4-Sure
Product
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Agent code
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Payment Mode*
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Variant (Cover type)*
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Duration of Cover*
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Amount Insured
₦
Amount Payable
₦
THE PROPOSER/APPLICANT
Surname*
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Other Names*
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Gender
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Date of birth *
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Address *
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Occupation*
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Phone Number*
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Alternate Phone Number
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Email Address*
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Disclose all existing health conditions*
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Staff ID Card [Upload]*
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EMPLOYMENT DETAILS/ACADEMIC DETAILS
Name of Employer*
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Address
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Phone Number
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Email Address*
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Date of Employment/Letter of Employment *
Date of Confirmation/Letter of Confirmation *
Position/Grade Level
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Highest Academic Qualification
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By submitting this form you agree that the above details provided are true and complete and the insurance company issues a Policy in its usual terms and conditions.