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Home
| HomeCall Change Request Form
HomeCall Change Request Form
Select Branch
*
Branch
Head Office
Asylum Down
Achimota
Teshie
Tema
West Hills
Ho
Koforidua
Takoradi
Cape Coast
Techiman
Sunyani
Kumasi
Harper Road Kumasi
Tamale
Bolga
Wa
Yendi
Agona Swedru
Hohoe
Tarkwa
Full Name
*
Policy Number
*
Current Phone Number
*
Email
CHANGE OF ASSURED(S)
DELETE
Full Name
Date of Birth
Relationship
Relationship
Husband
Wife
Father
Mother
Son
Daughter
Brother
Sister
Uncle
Aunt
Nephew
Cousin
Niece
Full Name
Date of Birth
Relationship
Relationship
Husband
Wife
Father
Mother
Son
Daughter
Brother
Sister
Uncle
Aunt
Nephew
Cousin
Niece
ADD
Full Name
Date of Birth
Relationship
Relationship
Husband
Wife
Father
Mother
Son
Daughter
Brother
Sister
Uncle
Aunt
Nephew
Cousin
Niece
Full Name
Date of Birth
Relationship
Relationship
Husband
Wife
Father
Mother
Son
Daughter
Brother
Sister
Uncle
Aunt
Nephew
Cousin
Niece
Does any Proposed Life Assured suffer any disease, disorder, paralysis or health impairment?
Select
Yes
No
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)
Select
Yes
No
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)
Select
Yes
No
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?
Select
Yes
No
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?
Select
Yes
No
Enter Full Name & Details
Has any proposed Life Assured been informed that he/she has been infected with HIV or is suffering from it?
Select
Yes
No
Enter Full Name & Details
ENDORSEMENT OF DATE OF BIRTH
Name of Assured
Date of Birth
Attach photocopy of valid ID
*
*Kindly attach a valid national ID card to complete process
BENEFIT PERCENTAGE CHANGE (BENEFICIARIES)
Name of Beneficiary
Date of Birth
New Percentage
Name of Beneficiary
Date of Birth
New Percentage
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.
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