Supreme Homecall Plan Form

Supreme Homecall Plan Form

  • [A] PERSONAL DETAILS

  • Drop files here or

    • PEP STATUS

    • [B] EMPLOYER DETAILS

    • [C] PAYMENT DETAILS

    • [D] COVER DETAILS


    • ASSUREDS

    • Principal Assured (not above 64 years)

    • Spouse (not above 64 years)

    • 1st Child (not above 23 years)

    • 2nd Child (not above 23 years)

    • 3rd Child (not above 23 years)

    • 4th Child (not above 23 years)

    • Mother (not above 74 years)

    • Father (not above 74 years)

    • Mother-in- law (not above 74 years)

    • Father-in- law (not above 74 years)

    • Extended Family Member: (Only 1 is allowed. Not above 74 years)

    • If at the time of claim it is discovered that the assured was more than the age limit at the inception of the policy, the company would only refund premiums.

    • BENEFICIARIES

      Please provide trustee if beneficiaries are below 18 years.

    • Beneficiary 1

    • Beneficiary 2

    • Beneficiary 3

    • Beneficiary 4

    • Beneficiary 5

    • Beneficiary 6

    • Beneficiary 7

    • Beneficiary 8

    • Beneficiary 9

    • Beneficiary 10


    • TRUSTEE(where a beneficiary is below 18 years of age)

      The trustee should be above 18 years


    • OPTIONAL BENEFIT FOR

    • [E] STATEMENT OF HEALTH

    • [F] HOW DID YOU GET TO KNOW STARLIFE?

    • [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.




    Speak to Broker's Team

      +233(0)302 317 892

      +233(0)556 784 093

      +233(0)549 524 798

      +233(0)244 822 342

    © 2022 Starlife Assurance.
    Powered by Exceed