1. QUESTION

State (in full) the name, profession or occupation, age and addres of the person claiming the policy moneys,together with his/her relationship to the deceased Life Assured.

1. ANSWER

2. QUESTION

What is the nature of title under which you claim the amount, eg. as executor, or administrator or assignee or beneficiary? if you are claiming on behalf of a minor state the exact nature on his/her behalf.

2. ANSWER

3. QUESTION

(a) State the name, father's name, last occupation, last and home addresses of the deceased.

3 (a). ANSWER

(b) State place and date of death, duration of last illness and the immediate cause of death of the Life Assured.

3 (b). ANSWER

4. QUESTION

Had the deceased any other assurance on his/her life? If so, state name of issuing office, year of issue and policy number.

4 ANSWER

5. QUESTION

(a) When did the deceased first complaim of not in usual good health?

5 (a). ANSWER

(b) Natur of illness then complained of?

5 (b). ANSWER

6. QUESTION

State the name of the medical attendants during the last illness.

6 ANSWER

7. QUESTION

Name and address of doctors consulted during the last three years, stating against each name the complaint for which he was consulted.

7. ANSWER

I hereby declare that the answers to each and all above questions are full and true in each and every respect.

Signatures:

N.B THIS STATEMENT MUST BE COUNTERSIGNED BY A MAGISTRATE; A COMMISSIONER OF OATHS; A NOTARY PUBLIC; A HEADMASTER OF A SECONDARY SCHOOL AN ADVOCATE OR SENIOR CIVIL SERVANT NOT BELOW THE RANK OF EXECUTIVE OFFICER.