ACCIDENT PLAN Creditstar Microinsurance

CREDITSTAR MICROINSURANCE COMPANY LIMITED (RC 1596638)

No 120, IKOTUN-EGBE ROAD, EJIGBO, ISOLO, LAGOS STATE

Tel: +23490877325 E-mail: info@mycreditstar.com Website: www.mycreditstar.com

NOTE: “AN INSURANCE AGENT 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”

THE LIABILITY OF THE INSURERS DOES NOT COMMENCE UNTIL ACCEPTANCE OF THE PROPOSAL AND FULL PAYMENT OF THE PREMIUM.

PLEASE USE BLOCK CAPITALS

PROPOSERS PERSONAL INFORMATION

Title:

Telephone No:

Email:

Surname:

First Name:

Others:

Residential Address:

Town/City:

Local Government Area

Date of Birth:

Occupation:

Gender:

Marital Status:

Means of Identification:

Upload ID:

Do you have any known medical challenges?:

If yes, state the type of sickness

Emplyment Status

Name of Business/Employer

Address of Business/Employer:

Name of Coop Society/Club:

Members Number:

Proposed Commencement Date:

DECLARATION

I/We, hereby declare that the information provided by me is accurate and true to the best of my knowledge.

Signature:

Date:

CREDITSTAR MICROINSURANCE COMPANY LIMITED (RC 1596638)

No 120, IKOTUN-EGBE ROAD, EJIGBO, ISOLO, LAGOS STATE

Tel: +23490877325 E-mail: info@mycreditstar.com Website: www.mycreditstar.com

PROPOSERS PERSONAL INFORMATION

DECLARATION

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