VANGUARD LIFE ASSURANCE COMPANY LIMITED
PROPOSAL & DECLARATION FOR POLICY FORM
TO
:
VANGUARD LIFE ASSURANCE COMPANY LIMITED
NAME OF INSTITUTION :
…………………………………………………………………………….
OCCUPATION
…………………………………………………………………………….
:
PHYSICAL ADDRESS OF INSTITUTION ……….……………………………………………………………
.….…………………………………………………………………
……………………………………………………………………
We hereby confirm that:a)
We wish to assure with Vanguard Life Assurance Company Limited the benefits of the Group
Pension and Life Assurance Scheme.
b)
We also request you to issue the appropriate policy stipulating the terms and conditions of your
insurance.
c)
i)
We intend making payments to you effective …………........................................................
at the following rates:
% of salary
Employee Contribution
……………
Employer’s Contribution
……………
Administration Charge
……………
Group Life Assurance
……….…… Multiple: ………………………………………...
Other (……………………….) …………………………………………………………….………
TOTAL
____________
EVIDENCE OF HEALTH FREE LIMIT: ………………………………………..…….…….……
ii)
We authorize you to apply these payments in accordance with your current
General Conditions of the policy.
We understand that the policy will contain Vanguard Life’s normal conditions relating to the
calculation of premium and its right to amend the terms and conditions subject to prior consultation
with ………………………………………………………………………………………………………….…..
Signature of Principal Officer: …………………………………..……………….
Date:.……………………………
Designation:…………………………………… Witness:…………..………………… CO. Stamp: