Pru-Farewell

Pru-Farewell Plan

Principal Member's Details

Full Names? *

Date of Birth? (Min and max entry ages are 18 - 65) *

Basic Sum Assured? (Minimum: UGX 1M, Maximum: 50M) *

Want an Escalation rider for the cover? *

Prefered Premium Payment Frequency? *

Additional Life Assured Members

Key Notes:

Age limit for children is from 0 to 74 years, while that of the extended family members is from 0 to 74 years.
The spouse benefit can range from 50% -100% of the Principal Member Cover.
Children and Extended family members’ benefits are set at a maximum of 50% of the Principal Member cover.
Additional members can only have the Escalation Rider only if the Principal member has it as well.

Add Member

Members Full Names:

D.O.B:

Relationship:

Sum Assured:

Escalation rider:

Added Members Details

Full Names

Age next BD

S.A

Rider

All questions must be answered in full, and all information given must be accurate. Failure to do so may render the policy Null and Void. Dashes will not be accepted. If in doubt, please contact the Bank or our Head Office at the address provided on this Form.

Section A- Life Assured's Details:

Principal Member's Bio Data

Title *

Surname *

Other Names *

Date of Birth *

Gender *

Marital Status *

Nationality *

Current Location *

Specify location, if not Uganda

Type of ID *

NIN/Passport/Driving License Number *

Address, Employment & Contact Details:

Residential Address *

Preferred Contact (0790000000) *

Other Contact (0790000000)

Email Address *

Occupation *

Name of Employer

Employer's Address

Section B- Details of Assurance:

Total Payable Premium (Ugx)

Payment Frequency

Section C- Premium Payment Details:

Mode of Payment *

Section D- Next of KIN Details and Additional Members:

Next of Kin to Principal Member-To whom benefits of the principal member are paid.

Full Name *

Relationship to Life Assured *

NIN/Passport/Driving License Number:

Telephone Number: *

Additional Lives Assured

In the event that an addtional life assured dies before the principal member, the benefits are paid to the principal

Full Names (Relationship)

Birthday

Sum Assured

Escalation Rider

Section E- Health Details:

Where any question is answered “Yes”, please give full and accurate details in the space provided. (Please answer all questions to best of your knowledge)

Are you currently undergoing, or have you been advised to undergo any form of medical treatment, medication or medical follow up? *

If yes, please provide details

Have you undergone any surgical operation in the past 5 years? *

If yes, please provide details

How many times have you been hospitalized in the last 6 months? *

Are you currently in a good health state? *

If no, please provide details

Section F- Agency Details:

Name of Agent/FSC

Agency/FSC No

I declare to the best of my Knowledge and belief that I have read the Key Facts Document (Policy Terms & Condtions) for this product and have understood the information provided to me. I declare that the statements and the particulars given in this form are to the best of my Knowledge true and complete and that I have not withheld any facts, which might be considered material to this Insurance

In case of any enquiries, please feel free to reach out to us:
Tel: +256 312 251 400 | Email: customercare@prudential.ug