Proposal/Application Form

Uni-Group Cover
Product
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Agent code
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Payment Mode*
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Variant (Cover type)*
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No of Members to be insured
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Amount Insured
₦
Amount Payable
₦
THE PROPOSER/APPLICANT
Group name*
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Group type*
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Registration number*
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Date of registration *
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Group Contact Address *
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First Person Name*
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Phone Number*
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Second Person Name*
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Phone Number
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Group Email Address*
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LIST OF GROUP MEMBERS TO BE INSURED
Member 1
Fullname
Gender
Occupation
Date of birth*
Next-of-Kin
Phone number

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.

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