CLAP Data Form - SMOOTHWAY INSURANCE BROKERS

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LBSL-RRS

CLAP

COMPREHENSIVE LIFE ASSURANCE PLAN

CLAP

Data Form for Enrolment

Step 1 of 4 - Personal Data

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Person Insured
Policy Number
Sum Insured
Enrollee Address
Annual Premium
Beneficiary Name
Insurance Company
Enrollment ID
Name*
Title First Middle Last
Marital Status
- Married
- Single
- Divorced
- Widow
Address
Work Phone
Mobile Phone
Email*
Occupation
Please give full details
Nationality
State of Origin
Place of Birth
Date of Birth
Date Format: DD slash MM slash YYYY
Evidence of Age
BVN Number*

Desired Benefits*
- Death
- Permanent Disability
- Temporary Disability
- Hospital Bill
- Burial Expenses
Death*
Amount: ₦ 250,000 Quantity:
Desired Benefits (Death)Total
Amount: ₦ 0
Premium (Death)
Amount: ₦ 0
@1%
Permanent Disability
Amount: ₦ 250,000 Quantity:
Desired Benefits (Disablility)Total
Amount: ₦ 0
Premium (Disability)
Amount: ₦ 0
@0.075%
Temporary Disability
Amount: ₦ 5,000 Quantity:
Desired Benefits (Temporary Disablility)Total
Amount: ₦ 0
Premium (Temporary Disablility)
Amount: ₦ 0
@12.5%
Hospital Bill
Amount: ₦ 50,000 Quantity:
Desired Benefits (Hospital Bill)Total
Amount: ₦ 0
Premium (Hospital Bill)
Amount: ₦ 0
@1%
Burial Expenses
Amount: ₦ 50,000 Quantity:
Desired Benefits (Burial Bill)Total
Amount: ₦ 0
Premium (Burial Bill)
Amount: ₦ 0
@1%
Total Premium
Amount: ₦ 0
Name of Beneficiary(ies)
Name (1)*
Relationship (1)
Name (2)
Relationship (2)
Commencement Date
Date Format: DD slash MM slash YYYY

Name and Address of your usual Medical Doctor
Details of treatments received in the past 5 years
Height (M)
Weight (kg)
Gender
Daily Consumption of Alcohol
Daily Consumption of Tobacco
Are you pregnant?
- Yes
- No
Expected Month/Year of Delivery
Tuberculosis, Asthma, Pneumonia or any other chest disease?
- Yes
- No
If Yes, please give details. Date/Duration
Indigestion, Gastric or duodenal ulceration, Jaundice, Gall-bladder?
- Yes
- No
If Yes, please give details. Date/Duration
Nervours disease or nervous breakdown, frequency headaches?
- Yes
- No
If Yes, please give details. Date/Duration
Any infection of the kidney, urinary or genital organs, renal stones, difficult or painful urination, blood in urine?
- Yes
- No
If Yes, please give details. Date/Duration
Recurrent or persistent fever, skin disorder?
- Yes
- No
If Yes, please give details. Date/Duration
Persistent Night Sweat?
- Yes
- No
If Yes, please give details. Date/Duration
Weight Loss?
- Yes
- No
If Yes, please give details. Date/Duration
Glandular infection or swollen glands?
- Yes
- No
If Yes, please give details. Date/Duration
Glandular infection or swollen glands?
- Yes
- No
If Yes, please give details. Date/Duration
Chronic or Frequent Diarrhoea?
- Yes
- No
If Yes, please give details. Date/Duration
Persistent Cough?
- Yes
- No
If Yes, please give details. Date/Duration
Hepatitis B or any sexually transmitted disease including genital sores or discharges?
- Yes
- No
If Yes, please give details. Date/Duration
Have you been refused as a blood donor?
- Yes
- No
If Yes, please give details. Date/Duration
Have you ever received any blood transfusions within the last 5 years?
- Yes
- No
If Yes, please give details. Date/Duration
Undergone any surgical operation?
- Yes
- No
If Yes, please give details. Date/Duration
Had an X-ray of the chest, stomach or any other organ?
- Yes
- No
If Yes, please give details. Date/Duration
Had an electrocardiogram (ECG), blood studies or other special investigations or tests not mentioned above?
- Yes
- No
If Yes, please give details. Date/Duration

Has any proposal on your life ever been made?
- Yes
- No
Sum Assured
Policy Number
Insurance Company
Preferred Insurance Company
Declaration*
I declare that all the above statement and answers are true and complete in every respect and that this proposal shall be the basis of the policy issued hereon
I authorise any medical doctor, financial institution or other person(s) to disclose any knowledge or information pertaining to my health or finances and waive all provisions of law forbidding the disclosure of such knowledge or information.

I further agree that if any untrue statement be contained in this proposal, all moneys which shall have been paid on account of the said assurance shall be forfeited and the assurance shall be absolutely null and void.

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