Registration Form ~Business & Personal Cover

Business & Life Insurance Application Form

Please complete this form to apply for our Business Insurance and/or Personal Life Insurance solutions. Fields marked with * are required.

1. Applicant Information

• Full Name / Company Name: *
• Type of Application: * ☐ Business Insurance Only ☐ Personal Life Insurance Only ☐ Both Business and Personal Life Insurance
• ID / Company Registration Number: *
• Contact Person (for Business):
• Email Address: *
• Phone Number: *
• Physical Address: *

2. Business Insurance Section

(Complete if applying for Business cover)

• Business Name (if different from above):
• Industry / Nature of Business: *
• Year Business Started:
• Number of Employees:
• Annual Turnover / Revenue:
• Business Premises: ☐ Owned ☐ Rented ☐ Home-based ☐ Multiple Locations
• Key Assets to be Insured (select all that apply): ☐ Buildings & Property ☐ Stock & Inventory ☐ Office Equipment & Machinery ☐ Vehicles / Fleet ☐ Public Liability ☐ Professional Indemnity ☐ Employers Liability / Workers Compensation ☐ Business Interruption ☐ Other (please specify):
• Current Insurance Policies (if any):
• Any previous claims in the last 5 years? ☐ Yes ☐ No
  • If Yes, provide details:

3. Personal Life Insurance Section

(Complete if applying for Life cover)

• Date of Birth: *
• Gender: *
• Marital Status:
• Occupation / Job Title: *
• Smoker Status: ☐ Smoker ☐ Non-Smoker
• Do you have any pre-existing medical conditions? ☐ Yes ☐ No
  • If Yes, please provide details:
• Beneficiaries:
  • Primary Beneficiary Name & Relationship:
  • Secondary Beneficiary (if any):
• Cover Amount Required: *
• Policy Term Preferred: ☐ Term Life (e.g. 10, 15, 20 years) ☐ Whole Life / Lifetime Cover ☐ Investment-Linked Life Insurance

4. Additional Information

• Total Combined Cover Required (if both Business & Life):
• Special Requirements or Specific Risks/Needs: (e.g. key person insurance, group life cover, partnership protection, etc.)
• How did you hear about us?

5. Declaration

I/We confirm that all information provided is true and complete. I/We understand that any misrepresentation may affect the validity of the policy.

e-Signature: