Centenary-Product

Diaspora Funeral Cover

Applicant's Details

Full Names: *

Date of Birth: *

Gender: *

ID Type: *

ID Number: *

Attach ID (5MBs Max): *

Country Code: *

Contact: *

Email Address: *

Physical Address: *

Cente Diaspora Account No: *

Account Names: *

Next of Kin Full Names: *

Next of Kin Email Address: *

Next of Kin Contact: *

Next of Kin Relationship: *

Diaspora Funeral Cover Packages

The premium payable per life assured. If an Account Holder has one child, under the gold package the premium payable is US$ 39. If the Account Holder has 2 children, the premium payable for both is US$ 39 x 2, for 3 children the premium is US$ 39 x 3 etc.

Package *

Product Cover: *

Number of persons covered: *

Declaration

PRODUCT KEY FACTS DOCUMENT

I declare to the best of my knowledge and belief that I have read the terms and conditions for this product and have understood the information provided to me. I declare that the statements and 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