Supreme Homecall Plan Form | StarLife Assurance

Supreme Homecall Plan Form

Supreme Homecall Plan Form

[A] PERSONAL DETAILS
Surname*
Middle Name(s)
First Name*
Date of Birth*
Nationality
Upload Passport & Residence Permit
Drop files here or
Gender
- Male
- Female
Are you Pregnant?
- Yes
- No
How Long
Marital Status
- Single
- Married
- Divorced
PEP STATUS
Are you a politically exposed Person?
- Yes
- No
Is any family member or known close associate a PEP?
- Yes
- No
Permanent Postal Address
Residential Address
Mobile
Email
ID Type
- Passport
- Voters’
- Drivers’
- National ID
- NHIS
ID Number
Date of Issue
Date of Expiry

[B] EMPLOYER DETAILS
Occupation
Name of Employer & Work Place Address
Telephone
Facsimile
Email

[C] PAYMENT DETAILS
Payment Mode
- Controller
- Institution
- Debit Order
- Cash/Cheque
- Mobile Money
Staff ID No.
Institution Name
State Bank
Branch
Bank A/C No
Payment Frequency
- Monthly
- Semi-Annually
- Quarterly
- Annually
Source of Income
- Salary
- Business
- Other
Nature of Business
Other Source of Income

TRUSTEE(where a beneficiary is below 18 years of age)
The trustee should be above 18 years
Surname
First Name
Other Names
Date of Birth
Relationship
Address/Contact No
Do you wish to have the Benefits Increase option?
- Yes
- No
Preferred option
- 5% Annual Premium Increase & 3% Annual Sum Assured Increase
- 10% Annual Premium Increase & 6% Annual Sum Assured Increase
- 15% Annual Premium Increase & 9% Annual Sum Assured Increase
OPTIONAL BENEFIT FOR
Personal Accident (Cover ends at Age 60)
- Yes
- No
GH₵ Annual Benefit
- 5,000
- 10,000
- 15,000
- 20,000
Hospitalisation Benefit (Cover ends at Age 60)
- Yes
- No
GH₵ Annual Benefit
- 1,400
- 2,500
- 3,600
- 5,000

[E] STATEMENT OF HEALTH
Do you or any of the Proposed Life Assured suffer any disease, disorder, paralysis or health impairment?
- Yes
- No
Full Details
During the past 12 months did any Proposed Life Assured suffer from Respiratory or lung disorder (e.g Persistent tuberculosis, spitting of blood, recurrent lung infection, difficulty in breathing)
- Yes
- No
Full Details
During the past 12 months did any Proposed Life Assured suffer from A disease or disorder of the bladder or reproductive organs (e.g. Blood or albumin in the urine, chronic discharge, difficulty in passing urine, venereal diseases)
- Yes
- No
Full 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?
- Yes
- No
Full 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?
- Yes
- No
Full Details
Has any Proposed Life Assured been informed that he/she has been infected with HIV or is suffering from it?
- Yes
- No
Full Details
Do you or any of the Proposed Life Assured have any sickle cell condition?
- Yes
- No
Full Details

[F] HOW DID YOU GET TO KNOW STARLIFE?
How Did You Get To Know StarLife?
- Advertisement
- Website
- Referral
- Agent
- Broker
- Others
Specify

[G] DECLARATION
I declare that every statement in response to questions asked in this application is true and correct to the best of my knowledge. I agree that this application shall serve as the basis and form part of the contract. All the questions have been explained to me in the language that I understand and I have been made to understand that this contract shall become operative until all of the following conditions have been met:
1. This application has been approved by StarLife Assurance Company Limited.
2. The appropriate premium has been paid.
3. I satisfy all the conditions precedent to the policy especially those pertaining to my health and that of all the proposed lives assured.
4. All the persons proposed for cover are alive and in good health.
Declaration*
- Yes, I agree
- No, I do not agree
Signature
Full Name*
Date

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