CLAP COMPREHENSIVE LIFE ASSURANCE PLAN CLAP Data Form for Enrolment Step 1 of 4 - Personal Data 0% Person Insured Policy NumberSum InsuredEnrollee AddressAnnual PremiumBeneficiary NameInsurance CompanyEnrollment IDName* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Middle Last Marital StatusMarriedSingleDivorcedWidowAddressWork PhoneMobile PhoneEmail* OccupationPlease give full detailsNationalityState of OriginAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEnuguEdoEkitiGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraPlace of BirthAbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEnuguEdoEkitiGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfaraDate of Birth Date Format: DD slash MM slash YYYY Evidence of AgeBVN 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 DoctorDetails of treatments received in the past 5 yearsHeight (M)Weight (kg)GenderMaleFemaleDaily Consumption of AlcoholDaily Consumption of TobaccoAre you pregnant?YesNoExpected Month/Year of DeliveryTuberculosis, Asthma, Pneumonia or any other chest disease?YesNoIf Yes, please give details. Date/DurationIndigestion, Gastric or duodenal ulceration, Jaundice, Gall-bladder?YesNoIf Yes, please give details. Date/DurationNervours disease or nervous breakdown, frequency headaches?YesNoIf Yes, please give details. Date/DurationAny infection of the kidney, urinary or genital organs, renal stones, difficult or painful urination, blood in urine?YesNoIf Yes, please give details. Date/DurationRecurrent or persistent fever, skin disorder?YesNoIf Yes, please give details. Date/DurationPersistent Night Sweat?YesNoIf Yes, please give details. Date/DurationWeight Loss?YesNoIf Yes, please give details. Date/DurationGlandular infection or swollen glands?YesNoIf Yes, please give details. Date/DurationGlandular infection or swollen glands?YesNoIf Yes, please give details. Date/DurationChronic or Frequent Diarrhoea?YesNoIf Yes, please give details. Date/DurationPersistent Cough?YesNoIf Yes, please give details. Date/DurationHepatitis B or any sexually transmitted disease including genital sores or discharges?YesNoIf Yes, please give details. Date/DurationHave you been refused as a blood donor?YesNoIf Yes, please give details. Date/DurationHave you ever received any blood transfusions within the last 5 years?YesNoIf Yes, please give details. Date/DurationUndergone any surgical operation?YesNoIf Yes, please give details. Date/DurationHad an X-ray of the chest, stomach or any other organ?YesNoIf Yes, please give details. Date/DurationHad an electrocardiogram (ECG), blood studies or other special investigations or tests not mentioned above?YesNoIf Yes, please give details. Date/Duration Has any proposal on your life ever been made?YesNoSum AssuredPolicy NumberInsurance CompanyPreferred Insurance CompanyAllianz Nigeria Insurance Plc.Anchor Insurance Co. LtdARM Life Assurance Plc.AXA Mansard Insurance Plc.Capital Express Assurance Co. LtdConsolidated Hallmark Insurance PlcCornerstone Insurance PlcCustodian & Allied Insurance PlcCustodian Life Assurance LimitedFBN General Insurance Co. Ltd.FBN Life Assurance Ltd.Fin Insurance Plc.Goldlink Insurance PlcGreat Nigeria Insurance PlcGuinea Insurance PlcIndustrial & General Insurance Plc.International Energy Insurance Plc.Jaiz Takaful Insurance Plc.KBL Insurance Ltd.LASACO Assurance PlcLaw Union & Rock Insurance PlcLeadway Assurance Co. LtdLinkage Assurance PlcMetropolitan Life Insurance Nig. LtdMutual Benefits Assurance PlcMutual Benefits Life Assurance Plc.NEM Insurance PlcNICON Insurance LimitedNiger Insurance Plc.Noor Takaful PLCNSIA Insurance Company LtdOld Mutual Nig. General Ins. Co. LimitedOld Mutual Nigeria Life Assurance CompanyPrestige Assurance Plc.Prudential Zenith Life Insurance Plc.Regency Alliance Insurance Plc.Royal Exchange General Insurance Co. LtdRoyal Exchange Prudential Life Plc.Saham Unitrust Insurance Nigeria Ltd.Sovereign Trust Insurance Plc.STACO Assurance PlcStandard Alliance Insurance Plc.Sterling Assurance Co. Ltd.Sunu Assurance Nigeria Plc.Universal Insurance PlcVeritas Kapital Assurance PlcWapic Insurance Plc.Wapic Life Assurance LtdZenith General Insurance Co. LtdDeclaration* 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 hereonI 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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