REQUEST FOR INDIVIDUAL INSURANCE QUOTEHealthLife InsurancePension and AnnuityHealthHealth InsuranceName* First Last Date of Birth* DD slash MM slash YYYY Email* Contact Number*Gender*MaleFemaleType of Coverage* Member Member & Child Member & Spouse Member & Family ( 3 or more Persons)Type of Policy* 1) Gold Care Plan – $500,000.00 2) Platinum Care Plan – $1,000,000.00 Life InsuranceLife InsuranceName* First Last Date of Birth* DD slash MM slash YYYY Gender*MaleFemaleAre you a smoker?*YesNoType of PolicyTraditional Life:* Whole Life LPU to age 65Term:* 5 years Renewable 20 years RenewableAges* 65 years old 70 years old 80 years oldEndowment at age 65*YesNoPeace AssuredPayment Duration* 10 years 80 years 100 yearsFace Amount*N.B Minimum 25,000.00 and Maximum $60,000.00Benefits* Accidental Death Dismemberment Premium Waiver RepatriationDesired Premium* Monthly Annually Single Pay Pension and AnnuityPension and AnnuityName* First Last Date of Birth* DD slash MM slash YYYY Email* Contact Number*Gender*MaleFemaleAre you a smoker?* Yes NoType of Annuity/Pension* Immediate Deferred* Registered Non-RegisteredMaturity Age* 60 65 70 OtherPremium Wavier Benefits* Yes NoDesired Premium $* Monthly Annually Single Pay
