APPLICATION FOR REINSTATEMENT/RE-DATING OF POLICY Si cl he trees for sntaenet/ dtr of my ey Ep p/sis/ 000. Sarees Loocy nate) with ffect from fH doy of APB 20.22, Fer the purpose of hs ame the nero) il snd fry es ined er he pokey” STATENENTS BY THE POLICY OWNER Allenawere mut be definite. dosh or N/A wil at be accepted ae arp Filo tabc ire SAMVEL OTe WARIGAY OTIENO Postal Address. eee re a Postal Code_o © 2. 2Dcity(Tou) Aiko Tica ONEEEL Se eens tema yabrcem Dote of birth _Q/ 0F/ 19S bE TD Number _2 3s oO Deyat oda arin a henner can i i, inanenerivg, mtr racing orig?) 6. Tf yes plese ge farther det 8. HeaLTit 1H yeu inthe past to years for any reason whtssever contd any medical dactoro specials, or “attended any hospital or lnc or urergone ary medical investigation, indy ECG, X-ray or othar Investigations or hesitation? (IC (Lf yes, give full etal below) 2.Hove yeu ever had ay ofthe flor Disease or disorder of the hdres, sti, seal trnsnted Gecaer or IV nfcon) "LES at ys gel deta elo) Are younow free from ll campldnis disease or abnormalities (congenial or ethervise) and inal respects inagood heath state ES.” afm, give full deta beow) DETAILS TO ANY YES ANSWERS FROM SECTION 8 ABOVE ‘Complaint or [Nature ord duration [Date | Noms, inils ond | When last dd you have symptoms | end daetion of ‘dress of attending | symptoms and/or what were lavetigatons the results ofthe Investigations or dlgnase?, GENERAL ‘nat mentioned elsewhere inthis pplleation are there any other circumstances related theath (ast or preset), ocapationor ates, which ight affect the assessment of the sk for fe insurance proses? S 1, DECLARATIONS 1. Tarrant that the infrmaton given in ths application and in ll dcuents wich hove been or sill be gna by me or the Life Assured in conction withthe policy ori renstatement is fue aed corect 12, Tages thatthe statemerts inthis aplication arin the documents mentioned above, sabe the tals ofthe policy ae restated, nd that ery misstatement er onasion therein may lead Yo the polcy being declared vd ay APA Life Assurance Ltd and that inaich event ll moneys pd in respect thereof shall beet the dsretion of the company 2, Thereby ievecably ahi and reqest ony docter or other person, wh may be in posession of te hereafter apr infomation concerning the health of the Life Assured to the te he paey Ieveinatated tala sch information APALifeAzsurance Ltd and T agree thet this authorty tne vequest sal remains force after the Life Assreds death wel a rior thereto. ‘4. Tunderstnd thot Faure diclove to APA Life Assirone Ltd, befere the ples reinstted, any Interalteretion ofthe facts upon which the decision of APA Life Assurance Lis based or any nes nj sufered 2th Life Assured between the date hereto andthe dete vpn wich the policy is reinstated may lat the pocy being declared vid by APA Life Assurance Ltd ond T ger that in such event ell meneys pln respect thereof shal be forfeited, 5, 1 the palcy wat a the tne aped, ceded fo APA Life Assirone Ld a ect far pai laa ether sich on was made Ye me ort, gree upon einatatement (Any oncnt thet wes ong to APA Life Assurance Ltd, whether i respect of capital ofthe lon or In respect ef interest orather charges thereon, immediately before the poly oped shall agin become ong by me to APA Life Assurnce Lt (0) the eason of the plc APA Life Assurance Lian the lon agreement shall aginbe in ful force ‘nd effect and binding upen ne ave that the loan opreenert shal be decd to hevebeen anerded bythe subtiuton of the provisions ofthe loon egreament currently being used in respec of loan ‘rated by APA Life Asarance L1d ot the tne of reinstatement, fr the rosie af the eiinal [ten agreement and save that as from the dae the ply peed interest ad ledge fees shall be payble atthe rate charged an plc loans being grated a the dete of reinsttenent, ifthe Joon hadcotinued in existence. i: dote_23/ 2093 nate 1 ony poser ih attain prem of le thn Teche (1) mente gy For rednig 2. the pay(er)hoe cam soared f geste har allen, the nae) wl be required Y0 90 for ‘deel eorrationontited yeu daar} ther om cas) 4 Flletsoncing pent for the purpose of renting wil be equrd ob pd baer the ple i rainstated te Bont wath of prensa fer he arose of retngOrignatortCompany ranch PDN 6 A | rectasoan: Soong) Cane poner ter acount uber ob eed ese atch cop of ak (ror ecu etl oe overt) CIIMDEPE Ee pain EDP /Holeoe cso Le, the poiléerpayer named lon, tere request, nrc a author you aw ast ay/aur cca a ‘raed abe wth th boven ono ay cern rch whch We may tantra the en rated whe arcantmceay fo: pment of the mony inament/remiom to he bsp) enon The ret payrent under hs order fate en tela of MA 2073 a sich thal rom my/our accu you ‘ute ened ye bey wet prom Live ude tht the ithdans by sured wil be proceed by Dect Debit Tasers ane ao ardent ‘Ts utr maybe cance by me's by thing you tity doy” note nw othe feof he above mentioned ‘th is tory wile ths thority wasn fe sch ames were ally own to ou. Ree of ts mah by you Nanni SARAVEL WARIGAtE OT/END mem tte stration FEA Qo 0 0/2 pW. 2Y6S5SF0 srountin words Taso Titus ctLings aNLY Ema Address:_(Sev ci gehs@y 4100-2 Yuthored ¥ Signatory Es a — mete: OF 27 ABE CF daried 2 Satay, ouz__23/0 P/20 23 reg: Caaty Comey Clermont Pom numbers _ POU THD yO ue ate: C15" Con Chis Cas Chao