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So uth Cumnin gsbtrg, Georgetortrn

Assuria"%Suttt,
UFEINSURAIIICE S&1.A
P.O. Box 10267
Tel.225-7# t2219675
Fufri-7173
Ernil address: guyana@ssu&.sr

APPUCATUI FORT
ForLift Insrance

Personalnumber: numben
Agent

Pdlqffider The lnsurcd


Sumarp name:
Fist nares (tu!!):
ld card/Passport#: Mfl Fl MDFL]
Date of Birh:

Place of Birh:

Addrcss:
Clty:

District / Counfiy:

Phone/ Fax number

MaritalStatrc ManiedEl Sinstetrl ManiedEl Singte E


Profession:
E-nniladdrcss:

Type of lnsunarrce:

Efiective Date:
Maturlty Date:
Sum lnsumd: Banker
Rider: Acount number.:
Dunation of lnsunance: Years Mon$s Mode of Pavrrent llg 6112 nontrs
Payment Method : Benk / 6h / dedudion oder

Premium calculation IAIIAGETEIITASSURN UFE fGN NC

601F1V0

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