INDIVIDUAL LIFE PUMZISHA PROPOSAL FORM Fl Name: OMARES DrepORAt NywNOVKO’ | Date of Birth: 2+ areal aga. Gender: av | PEMAxtE’ Marital status: S SiN LE® National: | Lemp National 1 Number(attach cpyes): | L gogocecae PIN Number (attach copy(ies) | AOI S$GG0g71¢ a | Nobite Number: pL onaugoboe, Postal Address, code & town: | 40-204, NAIROSI Email Address: \ dcbiahomare Ogmaal co Occupation: | Sette empoyees | Residential Address: \ NPA A0S1-— Neon RoAD, RAcewuet! vane of employer erdeatsorbuines serene | crores @ysiwets Relationship to Insured (to be completed by poticy owner anly): SELF € policy document willbe sent to your email address Paes GENCE ET} Frequency of Payment: Monthly [] Quarterly [] semi-annually ["] Annually [74 Nethod of Payment: Banker's Order[ —] Direct Debit] check off} n-Pesa [7/only anpicale to non-monthy payments: Pay bil 52760) ) Term: []5 Years [7] 6Years []7 Years [T]8 years [9 Years (if0 Years ") Total Premium: Kes. AZT ) Sum Assured: [57f Kes. 50,000 [—] kes 70,000 [—] Kes 100,000 {"] Kes 200.000 [] Kes 300,000 [—] kes $00,000 )) Kindly indicate Monthly Income: Less than Kes. 40,000[] Between Kes. 40,001 and 100,000 [—] Above Kes 100,001 [—] 1) Dependants Please list the members of your family you wish to include under the Pumzisha Cover i.e. parents, parents-in-law and children (maximum age of parents and parents-n-law is 69 years, whilst maximum age for children is 25 years) EmSeana Please note that ALL benefits are payable to the policy owner on the maturity date. Kindly nominate your beneficiary (is) to receive benefits in your absence. For more than one beneficiary, the percentage shared must add up to 100%. Gaara ne 5 cans cated eels Sag SHES) wt: AAS Rosa Re/efalaier00%6| too Tare] neTER Fee Ce te indirectly identify you. In order to provide you with products and services we need to collect, tse, sare a sore Your personal data, This may include information provided by you or obtained from Gird parties The hfrmation may be wed to asst us in providing the service you are applying for and shall be Used in futtiment of contractual obligations. We may also se. the information to advise you of other products and services provided by us, to confirm, update and enhance records and to establish your identity, Te data collected may be shared / transferred /stored Tpracessed within or outside the Kenyan jursdiction, Any reference to ewe" or Us" wil mean Apolo Group, Refer to our website voauapalnurance.org to ee the entitles under Apolo Group. (7. lauthorise APA Life Assurance to obtaln and use my personal Information as per the above Note: in case you would like to revoke the consent kindly send an ‘email to privacy@apollo.co.ke signature of Proposed sre... PRES FOR OFFICIAL SECTION EI Submitted requirements: Copy of 1[] Proof PN] atiorship | Full Nam _ state Ply Ome Meee eee or Ee i/We understand. that the statements and all number {information provided in this application form, whether in my/our own handwriting or not, are complete and true tothe best of my/our knowledge and that tt will form part of the paliey. 1W/ Change in amount, classification or benefits shall be effective unless agreed to in writing by the policy owner. YY Is also agreed that APA Life wil incur no lability under this appiication until, the application has been received and approved andthe premium has been paid and accepted by APA Ute. WW I/We understand that no intermediary has the authority to waive the answers to any of the question inthis application or tomake or alter any contract for APA Life Assurance. FY Me declare that I/We amn/are n good health and free from cisease or disability or any other symptoms thereof, untess o' ‘otherwise stated above under Section 4 of this form. \iWe consent to receive the policy document via the E-Mail address provided in Section 1 above and I/We also understand tat the policy document wil be considered detvered once Tabu ele2 Ty) Direct Debit/Check off form|_] Agency Manager: Gatun