Surname
Other Names
Business Name
Business Location
P.O. Box
City Region
Occupation Class
Hobbies/Pastimes ANB
Birth Of Date GenderMaleFemale
Marital Status : Single Married Divorced Widowed
Town
Telephone No
Email
3.BENEFITS
BASIC PLAN 1st Life Sum Assured Premium
GAP/GIP/ESP/GEEP/FIP ( )
GEMP
RIDERS
AI
HCI
TL
WOP/CEPA
INVESTMENT/SAVINGS
P/F


Do you or have you ever had any assurance on your life ?
Yes No

If,Yes Name of the Company ?

Commencement Date If with Glico   
Have you ever made a claim under any existing/previous policy ?
Yes No
Policy No :   Type of Claim :  

Automatic Annual Premium Increase
Please indicate annual percentage increase required
Protection Investment
10%   15%   20%   25%
Do you require any Anidaso Policy ?
Yes No
If Yes,state premium account
Do you require Automatic Monthly Premium Deduction from Edwa Nikosuo Policy ?
Yes No
Sub Total Premium  
Please indicate (D) for DEPENDENT LIVES ASSURED and (B) BENEFICIARIES
FULL NAME D/B DATE OF BIRTH ANB Sex Relationship HGT WGT TL/HCI SA Premium %
Sub Total Premium  
Grand Total  
4.HEALTH INFORMATION
PROPOSED LIFE
a. Are you at present suffering from any physical defect or is there any ailment or disease from which you suffer or to which you have a tendency to? Yes No
b. Have you at any time suffered from any illness or injury requiring medical or psychiatric/herbal attention? Yes No
c. Have you undergone any special investigation or laboratory tests or ever had a surgical operation? Yes No
d. Are you currently taking prescribed drugs, medicines, tablets or other treatment? Yes No

 

 

 


5. FAMILY HISTORY
LIVING DEATH
  Age State Of Health Age Cause Of Death
FATHER
MOTHER
 
SISTER
BROTHER
 
HEIGHT   WEIGHT  
e. Have you any intentions or prospect of engaging in any hazardous sports or other activities? Have you received medical advice or treatment in respect of AIDS of HIV related condition or any sexually transmitted disease? Yes No
f. Have you received medical advice or treatment in respect of Anaemia, Asthma, Tuberculosis. Ulcer, Syphilis, Rheumatism, Heart Disease, High Blood Pressure, Piles, Sickle Cell, Jaundice, Bilharzia, Leprosy, Chest Pain, Fit, Diabetes or any contagious disease? Yes No
g. Are you free from any physical deformity or defect of speech, vision and hearing? Yes No
h. Are there any other medical problem(s) relevant to the assessment of the risk? Yes No
Has any member of your family ever had :
a) Heart Ailment? Yes No
b) Nervous disease? Yes No
c) Diabetes? Yes No
d) Asthma? Yes No
e) Tuberculosis? Yes No
f) Cancer? Yes No
If any question is answered "Yes," please give full details (use extras sheet of paper, if necessary)
DISEASE OR INJURY DATE DURATION RESULT DOCTOR OR HOSPITAL
7.PROPOSED FEMALES
a) Are you pregnant?  Yes No
b) Have you ever had cancer or disorder of the breast or female organ or birth by caesarean section?  Yes No
c) No. of Children  Yes No
d) Any other female problem(s)? Yes No
8. Name and address of your regular Doctor and Hospital:
 
Give date you last consulted  
9. How many sticks of cigarettes do you smoke in a day?
 
When did you start smoking? 
10. What is your average consumption of alcohol?
 
When did you start drinking? 

EXCLUSIONS

The policy shall not cover pre-existing physical or mental defects, pre-existing diseases, gradually operating causes, pregnancy, self exposure in needless peril, suicide, drugs, war risks and the exclusions listed in the policy. In the event of death, while application has not been accepted or a policy issued by GLICO, actual amount paid shall be payable under a claim without interest. The application if accepted by GLICO shall be issued within 30 days from the date of first premium payment.


DECLARATION

I submit this application form with a view of entering into a contract for the benefits set out overleaf on GLICO normal terms and conditions. I have read over my answers to all the questions in this application form and I declare that, to the best of my knowledge and belief, all the information given are TRUE AND COMPLETE. I understand that in the event of my being medically examined the answers to be given by me to the medical examiner acting on behalf of GLICO shall be deemed to be incorporated in these applications. I consent to GLICO seeking medical information from any Doctor at any time who has attended to me concerning anything which affects my physical or mental health seeking information from any insurance office to which an application has been made for