HomeCall Change Request Form

Select Branch*
Full Name*
Policy Number*
Current Phone Number*
Email
CHANGE OF ASSURED(S)
DELETE
Full Name
Date of Birth
Relationship
Full Name
Date of Birth
Relationship
ADD
Full Name
Date of Birth
Relationship
Full Name
Date of Birth
Relationship
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
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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No. 3 Mankata Avenue, Behind National Service Secretariat, Airport Residential Area
P.O. Box AN 5783 , Accra – North Ghana

Call on: +233 (0) 302 739605

HomeCall Change Request Form

CHANGE OF ASSURED(S)

DELETE

ADD

ENDORSEMENT OF DATE OF BIRTH

BENEFIT PERCENTAGE CHANGE (BENEFICIARIES)

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