NSIA Insurance

BUY KEYMAN ASSURANCE

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Instructions
1. Please fill the form fields and upload all the necessary documents.
2. We will review the information and uploaded document and respond within few hours
3. Upon successful payment of premium, Policy Documents and certificates are automatically generated and sent to you via email.
4.Kindly check your spam/junk email inbox as well.
5.Please note: Upload file limit is 1MB.

Personal Information

Title *

Name (Surname First) *

Other Names *

Residential Address *

E-mail address *

Sex *

Marital Status *

Telephone Number *

Date of Birth *(Minimum age is 18 and Maximum age is 65)

Occupation

Position/Designation

Address of Business

TIN

Name of Agent

Policy commencement date *

Policy Tenor *

Sum Assured (Minimum of #500,000 and Maximum of 1 Million) *

Purpose Of Policy *

Premium *

Do you want Direct Debit Mandate Form?

Medical Informations

Height (CM)

Weight (KG)

Alcohol consumption *

Are you Pregnant? *

when is the EDD

Have you suffered or suffering from:*
Nil
Tuberculosis
Heart Disease
Diabetes

Do you usually enjoy good health? *

Please give details

Are you suffering from any terminal disease? *

Please give details

Check if you have any Policy/scheme with NSIA Insurance or other Companies *
NSIA Insurance
Another Insurance Company
Nil

Beneficiaries

Please note that the total beneficiarie(s) proportion must be 100

Full Name *

Relationship *

Benefit Proportion *

Sex *

Date of Birth *

Frequency of payment

Full Name	Relationship	Benefit Proportion	Sex	Date of Birth

Premium Calculation

Premium Amount

Frequency of payment

Next of Kin

Full Name*

Address*

Relationship*

Mobile no*

Policy Holder*

Relationship of the Policy Holder to the Assured *

Direct Debit Mandate

(Amount In Figures)

(Amount In Words)

Frequency of payment

This mandate which commences on

From Date

To Date

Bank Details

Bank Name

Account Name

Account Number

Branch

Type Of Account

Uploads

Upload Requirements

Valid Mean(s) of ID *

Utility Bill *

Upload Signature *

Declaration

I, the undersigned, do hereby declare that the above statements are true and complete.

I hereby give my consent to the Company, to seek information, if necessary, from any doctor who has ever attended to me from any Life Assurance Office, to which a Proposal on my Life, at any given time, has been made, and the giving of such information is hereby authorized.

I further agree that this Proposal, Declaration and the statements made above or to the Medical Examiner acting for the Company (where required) shall be the basis of the proposed life insurance contract; that if anything contrary to the truth be stated or if any information which ought to be made known to the Company with reference to the Proposed Assurance be withheld or concealed, any Policy which may be granted in pursuance of this contract shall be null and void.

Note:

The Company is bound only by documents bearing the signature of an official of the Company authorized to Sign on its behalf.
The Company is not on risk until acceptance of the Proposal has been communicated in writing and the First premium has been received at the Company’ Head Office.
Premium should be made through cheques or direct credit into NSIA Insurance Ltd 's account as NSIA would not be liable for premium paid in cash.

By checking the box , I agree with the above terms*

The data collection may be via hard copies or online forms, validated via JSON WEB TOKEN (JWT). The data will not be accessed by any third party without your consent and any breach of this Policy can be addressed legally within the year the breach was reported.