= a LIFE ASSURANCE PROPOSAL FORM Application No: Pease fil this form in ENGLISH and in BLOCK LETTERS. “NOTE: An Insurance Agent who assists an applicant to complet this application / proposal for Insurance shall be deemed to have done so as the agent of the applicant in accordance with section 54 (2) Insurance Act 2003. 1. Name of Applicant (As appearing in supprtng identfication documont) Tie! Surname | Other name | peje lie tad | Maiden Name Weeden | | size photograph and | owe (ae) Pore meena %. Marital Status C1 Single C) Married | | ze. daeotaien — OD) bE] MEDD) E | 3 Naeatty—C) Nigetan Sit of Og Non Ngeion 4 Resident! Status] Resiertndval Non Reser) Foreign Natal cma eam ea 5. Proof deity ob provided by applicant Cinta Cl met Poss] YoerCard (I Oring Leone Datectisue Date ot spy Identification No 6. Bank Verification Number (BVN) \ Psa 1. Residential Address, | | 2 Contact Detaits } [Mei ons LT Motte ere) | | ‘ neta I I | | | | | 3. _Proot of address. Please submit ANY ONE of the following valid documents & tick () against the document attached. Bi Tenancy Agreement} Registered Lease Purchase Agreement of Residence, (Latest Bank Account Statement Passbook 1 Latest Elecricty Bil] Lalest Gas BilLatest Waste BiNot more than 3 months 5d.) Latest Tlehone Bi 4. Pormanent Adress of Resident Applicant f diffrent from B1 above OR Overseas Address (Mandatory) for Non-Resident Applicant Geran 4. Gross Annual income Deas C) Below Nin C) NZS CI) NEAOm EC) NIE20 C)_NZOM above {oR} Netwoth niccdsieaascy mo ODED CTE 2 Occupation 1 Private Secor Serice C) Puble Sector) Government Senice C1 Business C1 Professional Cl Agruturst 1 Retres Cl Housewile Ci Student C1 ForexDealer Others Please spe 2. Principat 2e, Nature 24. How long employed: 3. Please tckif applicable: (1 Poitically Exposed Person (PEP) Cl Related io Politically Exposed Petson (PEP) 4. Any other information: 5. Proposed Commencement Date, I] i /(IEE 6a, Sum Assured: (6b. Rider: Waiver of Premium (WP) Accidental Death and Dismemberment (AX) 7. Source of Fund: 8. Duration of Plan C1 6 Years [1 9 Years 11 12,Years 1 18 Years 9. Frequency of Payment: [1 Monthy CI Half Yeary C1} Yeary | 10. Mode of Payment: (3 Cheque Direct Debit Note: AICO insurance Ple does not accept cash paymonts to any agentstaff ofthe company and accopts no liabilty for such. All payments shall be made through designated payment channols in favour of AICO Insurance Pl. ‘1. Deposit Premium Ma 12, Employment Status: C1 Employed Self Employed C) Others, Specify 13. Business/Occupation: | 14. Business Employer's Name: 15. Business Employers Address: [18 Bank Name ‘Account Number: Type: |1. Has any aplication fr any reinstatement of fe, Accident or Health Insurance ever been declined, postponed, rat ves Ovo | yes tate ti 2a, Whatlife insurance snow in fore on youre? 2b, Yeor isu 2e. company: 24 Amount 2a, Present State of helt 3b, Any deformity] Yes No |e nae ee [t= seen ves |4b, Consulted a physician? — Yes] No CI | |4c. Been under observation for any medical condition? Yes] Nol] es state details: 1. Name occupation Motil No: dees Felatinship (aloes share eationship SEN a occupation: Address: 2. Nae | occupation Address: Mobile No Peon hey echo preset god health an al the oegcing avers ae Ihave rok conceded or thes i ifition tk allel ligt fr Ue"Asurace Pan” {sree tu thane a statenets a have ade osha make to te Company in See ee Ae meen arene ent eres sine Eee | Snathatall payments shaibe made the name of AICO Insurance | Senisedbacaneetsea cimeoeromeelae ejamaicenee ‘hatin compliance wth relevant nws have considered all data request made by ACO with respect to my perznal date and hereby concede to ithoyt any elemento ru Toerese tung nloanes the rleaze of aa ntomystion | actnontedge fe have agus ers ond consfong by Teneo ny gs Sa gwar my Hg ot ‘ehalshol be getermines span execution op relevant document dna ttnexcson father att tis ine wh sevant aw, hae Ben ulna abot my ng husthdrualot consertanrelton to perzonal dots iesmaton usc shal eke unreasansbh wth SIGNATURE OF APPLICANT: Pace ate: 0 0 CoO ‘They othe company sal nt cman une th appeton acid, the premium pain accordance wh Secon) of marae At 2003, nd ply decimate ned Peer es wovene oof] EEI/HTETTSEET | orignal vet Sef erted Document copies recived | “9S /Avr0 Manners Sate ee ewe Tl catested) Tee copis of documents received ME ee ‘As customer of AICO insurance Pe fll Name), understand that AICO may calle, process, store and vs my rtena tao isenid here or the france ofthe poly convace|spned betwen Wise af Eistomed ond AC Bsa roe lanl purposes nine wth RICO Date Bay sd econ Foley andthe Nigran Ota Protection Ragulatone S079.NOPR 1am aso are thatthe personal dats required by AICO forthe purposes mentioned herein may ince personal data and sensitive personal data suc at my name er ‘dares ofe sdaress phone number detect bith mediaihstotyandeecordeand ether related Gat, 1am aware that ANCO may share my personal data withitsaffiates agents ensurance companies regulatory authors oh party sevice providers forthe purposes for tach tiscallecedorincomplanee wih provsions! appeal laws amalso aware! ACO wrt he persona datas lng es hecssary forthe puposetor whichis “alec Sy Maques and access perl Gata coleced and stored by AICO, fo) _ Wd 00% ed ing (Re ‘Riaptatlon and rdscation omy dtakeplby ACS, fe) Request fordelton of den) Beisormed tana eritedto rouge consent pont tne pocesing of ts | purposes oer an tht or wh he prion data were coed Ng) Request the movement of my data by AICO to Owed parties, and (h) Request that ANC restnets is resting any ntrmaton also confirm, that | have read and. understood the AICO ata Privacy and Protection Policy and the ALICO Privacy Notice avalable at tae cok omvindex hbtacy security Inconsderaton fal the nformation state hecin that ar within my knowledge, hereby consent the collection precessng use and transfer of my personal data within oF hide ger re purponrsateaheren Sos eee: | Adres: : : ae : =|