Enquiry/Amendment Request Form*

Request Type*

Enquiry Details

WebCs Request Type

WebCs Request Details

Request Details*

Correction/Amendment Details

Bridging Type

Documents Presented

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I hearby request for the reinstatement of my policy;

FUNERAL FINANCE POLICY, which is payment lapsed (within a year) due to lack of premium payments. By this request, I understand and agree that I have to settle all outstanding premiums and go through a six (6) month waiting period within which I am not entitled to make any death claims except for accidental deathFUNERAL FINANCE POLICY, which is payment lapsed (after a year) due to non – payment of my insurance premiums. By this request, I understand and agree that I have to settle all outstanding premiums and go through a twelve (12) month waiting period within which I am not entitled to make any death claims except for accidental death.LIFETIME NEEDS POLICY/EDUCARE POLICY, which is payment lapsed due to lack of payment. By this, I understand and hereby agree that I have to settle all outstanding premiums and sign a Declaration of Good Health Form.

PAYMENT ARRANGEMENT

I promise to make full payment of my outstanding premiums by the

Date

I promise to make payment of my first (1st) installment being 50% of the amount outstanding by

Date

I promise to make payment of my second (2nd) installment being 25% of the amount outstanding by

Date

I promise to make payment of my third (3rd) installment being 25% of the amount outstanding by

Date

I hereby declare that*

Since my last proposal I have not suffered from any illness or consulted a medical practitionerI am in good healthNo alteration has taken place in my family history

Last Proposal dated

Date

If there are any exceptions to the declarations above, please complete the following

Nature of Complaint

Name & Address of Attending Doctor or Hospital

Date of Last symptoms/ Results of the Investigations

I agree that this declaration shall be taken together with the proposal as the basis of the contract between the Enterprise Life Assurance Company Limited and me.

National ID Type*

National ID Number*

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TIN Number

Taxpayer Identification Number (TIN)

Sign your Signature*

National ID Type

National ID Number

Select Bank

Account Holder Name

Name of client on their bank account

Account Number

Branch Name

Branch Code

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Enquiry /Amendment Request Form