Impotant Information

  1. AN INDIVIDUAL WHO ASSISTS AN APPLICANT TO COMPLETE AN APPLICATION OR PROPOSAL FORM FOR INSURANCE SHALL BE DEEMED TO HAVE DONE SO AS THE AGENT OF THE APPLICANT IN ACCORDANCE WITH SECTION 54(2), INSURANCE ACT, 2003

  2. THE LIABILITY OF THE COMPANY DOES NOT COMMENCE UNTIL THIS APPLICATION IS ACCEPTED AND THE PREMIUM IS PAID IN ACCORDANCE WITH SECTION 50(1) OF INSURANCE ACT 2003

    Allianz Term Life Plan pays a benefit on the demise of the policyholder within the policy term. The policy also covers accidental death whereby twice the sum assured is paid, critical illness where 70% is paid on diagnose and the remaining 30% paid upon the death of the policyholder. The policy will pay out the sum assured in the event that the policyholder is diagnosed with Cancer. In addition, a funeral expense up to 10% of sum assured is paid to a limit of NGN 500,000.00

INDIVIDUAL PROPOSAL FORM

Please use BLOCK CAPITALS, insert YES or NO where appropriate and initial any amendments

  24. ANNUAL INCOME BAND (NGN):

  43. If yes, give details:

  44. Has any proposal on your life ever been declined, postponed, deferred, withdrawn or accepted on special terms?

  48. Have you served or applied for service or are you currently serving in the Armed Forces, Police, Customs or other paramilitary/security force

    If you have served in any, what was your medical grade on discharge

  49. Name and Addressof your Doctor

  50. HAVE YOU RECEIVED MEDICAL ADVICE OR TREATMENT IN CONNECTION WITH THE FOLLOWING

  51. IS THERE ANYTHING YOU HAVE SUFFERED FROM WHICH HAS NOT BEEN MENTIONED ABOVE?

  52. Please state any material fact, substance or information regarding your health and way of living which was not specifically mentioned above

  53. Give the following particulars as to your family history
    1. Father

      2. If Alive Give answers to the following questions:

        If Deceased:

    2. Mother

      2. If Alive Give answers to the following questions:

        If Deceased:

    3. FULL BROTHERS No. Born

      2. If Alive Give answers to the following questions:

        If Deceased:

    4. FULL SISTERS No. Born

      2. If Alive Give answers to the following questions:

        If Deceased:

      3. WIFE OR HUSBAND

        2. If Alive Give answers to the following questions:

          If Deceased:

  54. Are there any additional facts affecting the risk of assurance on your life of which the company should be made aware

  55. Particulars of Beneficiaries
    1. Primary
    2. CONTINGENT
  56. BANK ACCOUNT DETAILS
    1. Primary
    2. CONTINGENT
Declaration

I, declare and warrant that the above information in this application, and in all documents submitted to ALLIANZ NIGERIA INSURANCE Ltd in connection with this application, whether in own handwriting or not, is true, correct and complete and will form the basis of the proposed contract. I agree that if any material information concerning the risk on the life/lives insured has not been fully disclosed, or if I have given any untrue, incorrect or incomplete answers, ALLIANZ NIGERIA INSURANCE Ltd reserves the right to cancel my cover and I shall forfeit all premiums paid.

I irrevocably authorize and request any Doctor or other person who may be in possession of, or hereafter acquire any information concerning my health to disclose such information to ALLIANZ NIGERIA INSURANCE Ltd

RESTRICTIONS, WAR AND KINDRED RISKS

It is agreed and expressly understood that should the death of the life assured occur directly or indirectly from his/her engaging in or taking part in riot or strike, civil commotion, insurrection, war (whether war be declared or not) or any act incidental thereto, the total amount payable under this policy shall be limited to the total amount of the premiums actually paid under the policy (less all extra premiums and any amount already paid by the company under the policy) together with compound interest on the premiums so paid to the date of the death of the life assured, at the rate to be determined by the company provided always that the total amount so payable under the policy shall not be more than the value of the sum assured.

The Assurer shall not recognise any claim arising from any medical impairment or condition of a Life Assured which occurred or which was diagnosed prior to commencement of the term of assurance under this Policy, or within six (6) months of such commencement.

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