Family Protection Change Request Form

Select Branch*
Full Name*
Policy Number*
Current Phone Number*
Email
BENEFICIARIES
Beneficiaries To Be Deleted
ADD
Full Name
Percentage
Date of Birth
Relationship
Full Name
Percentage
Date of Birth
Relationship
TRUSTEE
Full Name
Relationship
Date of Birth
RIDERS
Do you require Spousal Cover?
Do you require Child Disability Cover?
Do you require retrenchment?
Is your gross salary GH¢1, 500 and above? (for formal sector only)
ADD: (Please Add Date of Birth, Age and Relation to Assured)
Full Name
Date of Birth
Relationship
Full Name
Date of Birth
Relationship
DELETE
Full Name
Date of Birth
Relationship
Full Name
Date of Birth
Relationship
MEDICAL
Does any Proposed Life Assured suffer any disease, disorder, paralysis or health impairment?
Enter Full Name & Details
During the past 12 months did any proposed Life Assured suffer from any respiratory or lung disorder (e.g. Persistent tuberculosis, spitting of blood)
Enter Full Name & Details
During the past 12 months did any proposed Life Assured suffer from any disease or disorder of the bladder or reproductive organs e.g Blood or albumi) In the urine, chronic discharge, difficulty in passing urine, venereal diseases)
Enter Full Name & Details
Is any proposed Life Assured at present receiving or has he/she during the past 12 months received any medication or treatment for longer than two weeks continuously?
Enter Full Name & Details
Did any proposed Life Assured consult any medical doctor or other persons providing Healing services (e.g. Herbalist, traditional healer) during the past 3 months?
Enter Full Name & Details
Has any proposed Life Assured been informed that he/she has been infected with HIV or is suffering from it?
Enter Full Name & Details
Your Address
Client Signature*
- By ticking, I hereby acknowledge that I have completely read and understand this form and all the information I have provided is correct.

Family Protection Change Request Form

BENEFICIARIES

ADD

TRUSTEE

RIDERS

ADD: (Please Add Date of Birth, Age and Relation to Assured)

DELETE

MEDICAL

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