Proposal Form

Langton Funeral Micro Insurance – fill in your details to get covered.

Policy Holder Details

First Names *

Surname *

Sex *

Date of Birth *

Policy Type *

Marital Status

Commencement Date

Employer

E.C number / Employer no

Employer Address

Occupation

Email Address *

Contact *

Gender

Premium payable ($)

Banking Details

Account Name

Account Number

Branch

Person Responsible for Premium Payment

Surname

Name

I.D number

Relationship

Contact No

Employer Address

E.C Number/Employer No

Next of Kin Details

Full Name

Phone No

Physical Address

Family Beneficiaries

Surname	Name	Sex	D.O.B	ID Number	Commencement Date	Relationship	Actions

I, , declare to the best of my knowledge that the details given above are true and correct. I am fully aware that only those registered above will get cover.

Signature of Principal Member

Date