Proposal/Application Form

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