LIFETIME NEEDS PLUS Policy Number GH 3 V 0 9 9 6 708 1

FRAUD WARNING: Knowingly presenting false information is a crime. Failure to disclose relevant information may
result in non payment of a claim and all benefits under the policy being cancelled

1. PERSONAL DETAILS OF PRINCIPAL LIFE ASSURED (POLICYHOLDER DETAILS)

First Name(s)
P O R S I A N - B E L I N I N I I S I
Surname

B A L O
ID Number Date of Birth (YYYYMMDD) Title Marital Status

GH A - 7 2 3 3 2 2 6 2 7 - 0 2 0 0 0 1 2 18 M I S S S I N G L E
Nationality Gender ID Type
F E MA L E I D
CONTACT DETAILS
Cell (Pre-fix for other countries) Work Phone Home Phone Fax
+ 2 3 3 2 0 3 873 4 6 5
Email

P O R T I A A F E T E Y@GMA I L . C O M
Addressee
POSTAL ADDRESS
Private Bag or P.O. Box Number Postal Code
P O B O X A I R P O R T
Street
G I Z
Suburb
A C C RA
Town

A C C RA
Region

G R E A T E R A C C RA
Employer Employee Number
EMPLOYMENT DETAILS
Basic Earnings Salary Pay Day Salary Payment Frequency Employment Date
GHc
Occupation
WO R K E R
2. SPOUSE DETAILS
First Name(s)

Surname

ID Number Date of Birth (YYYYMMDD) Title Marital Status

Gender Cell (Pre-fix for other countries) Home Phone

Work Phone

ID Type

3. TRUSTEE DETAILS
First Name(s)

L U C Y
Surname
J A M E S
ID Number Date of Birth (YYYYMMDD) Title Marital Status

1 9 9 7 0 303 M I S S
Gender Cell (Pre-fix for other countries) Work Phone Home Phone

F E MA L E + 2 3 3 2 0 6 639 4 6 2
ID Type

4. PRODUCT OPTIONS (PREMIUM DETAILS)

COVER LEVEL: Low N Medium Y High N
Monthly Premium Cash Bonus Premium Issue Date (YYYYMMDD)

1 0 0 . 00 2 0 2 4 0 7 04
Hospitalisation Cover Option: Hospitalisation Premium (GHC) Lumpsum Contribution (GHC)

Policy Fee: Total Premium

1 . 0 1 0 1 . 00 UPDATE OPTION: 0 % (0,5,10,15,20,25,30)

(MINIMUM TOTAL PREMIUM GHc 50)
LIFETIME NEEDS PLUS Policy Number G H 3 V 0 9 9 6 7 0 8 2
5. BENEFICIARY DETAILS

1 First Name(s) 7 First Name(s)

L U C Y
Surname Benefit Split (%) Surname Benefit Split (%)

J A M E S 1 0 0
Relationship Gender Date of Birth (YYYYMMDD) Relationship Gender Date of Birth (YYYYMMDD)

C E S S I O N A R Y F E MA L E 1 9 9 7 0 3 0 3

2 First Name(s) 8 First Name(s)

Surname Benefit Split (%) Surname Benefit Split (%)

Relationship Gender Date of Birth (YYYYMMDD) Relationship Gender Date of Birth (YYYYMMDD)

3 First Name(s) 9 First Name(s)

Surname Benefit Split (%) Surname Benefit Split (%)

Relationship Gender Date of Birth (YYYYMMDD) Relationship Gender Date of Birth (YYYYMMDD)

4 First Name(s) 10 First Name(s)

Surname Benefit Split (%) Surname Benefit Split (%)

Relationship Gender Date of Birth (YYYYMMDD) Relationship Gender Date of Birth (YYYYMMDD)

5 First Name(s) 11 First Name(s)

Surname Benefit Split (%) Surname Benefit Split (%)

Relationship Gender Date of Birth (YYYYMMDD) Relationship Gender Date of Birth (YYYYMMDD)

6 First Name(s)

Surname Benefit Split (%)

Relationship Gender Date of Birth (YYYYMMDD)

LIFETIME NEEDS PLUS GH 3 V 0 9 9 6 708
Policy Number 3
6. MEDICAL DECLARATION
Y/N
1. Are you presently in good health, free form disease and injuries and still have full use of your limbs and eyes? Y
2. Does your occupation, hobbies or pastimes involve you in any activity which may expose you to higher than average chance of premature death or N
becoming disabled (e.g. working iwth machinery or electicity, any type of aviation, climbing etc)?

3. In the past five years have you been examined by a doctor or been in hospital for treatment or examination or have you in the past or are you N
currently taking any drugs or prescribed medicine?

4. Have you ever been tested for or receive medical advice, counseling or treatment in connection iwth any sexually transmitted disease e.g. N
Hepatitis B, Gonorrhea, or Syphilis?
5. Has any life assurer ever refused an application on your life or charged an increased premium for health or occupational reasons? N
6. Is there a history in your family of diabetes, raised cholesterol, heart disease, stroke, high blood pressure, nervous or mental disorder, cancer, N
retinitis, pigmentosa, porphyria, haemophilia, or any other hereditary disease? If "YES" please provide details in the answer section
1 . 0 cm
7. Height (without shoes) in centimeters:
7 5 kg
Weight (in normal clothes) in kilograms: Y/N

Has your weight changed by more than 5 kilograms during the past year? N
If "YES" please state: Reason for change, amount of change, and present weight-constant for months in the answer section
8. ALCOHOL CONSUMPTION - 0 How many glasses of wine do you drink per week? 0 What is the total of spirits you drink per week? 0
How many 340ml beers do you drink per week? Y/N
Have you ever consumed more alcohol in the past? If "YES" please provide full detauls in the answer section N
9. SMOKING - Do you smoke? N
If "YES" How much do you smoke per day?

What do you smoke?

If the answer is "Y" to questions 1-6 above please provide details below.
Health Concern Health Concern Description

Date Health Concern Result

Health Concern Health Concern Description

Date Health Concern Result

Health Concern Health Concern Description

Date Health Concern Result

Health Concern Health Concern Description

Date Health Concern Result

Name of Clinic / Hospital attended in the last 5 years: Telephone Number

Name of Usual Medical Doctor Telephone Number

7. EXISTING POLICIES
Y/N
1. Do you have an existing, or are you presently applying (excluding this application) for life insurance with this or any other insurance company?

2. Is this application to replace the whole or part of any application or to replace all or part of existing assurances with any assurance company
(whether replacement is to occur immediately or to replace an assurance discontinued within the past six months or to be discountinued within the
next six months)?
IMPORTANT - Replaces of any Assurance is nearly always to the disadvantage of the Policyholder because it involves duplication of initial cost charges
IF THE ANSWER TO QUESTION 1 OR 2 IS "YES", PLEASE PROVIDE FULL DETAILS IN THE SPACE BELOW
Question No. Name of Company Policy Number Sum Assured
LIFETIME NEEDS PLUS GH 3 V 0 9 9 6 708
Policy Number 4
8. PAYMENT DETAILS
Commencement Date 2 0 2 4 0 8 01 Please tick one of the options below
Enterprise Life will change this date according to circumstances 1 Stop Order * Please fill in Stop Order Details
Payment Frequency 2 Debit Order Y * Please fill in Debit Order Information
MO N TH L Y 3 Mobile Wallet * Please fill in Mobile Wallet Information

9. PAYER DETAILS
First Name(s)

P O R S I A N - B E L I N I N I I S I
Surname

B A L O
ID Number Date of Birth (YYYYMMDD) ID Type
GH A - 7 2 3 3 2 2 6 2 7 - 0 2 0 0 0 1 2 18 I D

10. DEBIT ORDER INFORMATION

To avoid high bank penalty charges, as well as the possibility of the policy lapsing - please ensure you have enough money in your account each month
on the day you have chosen for your debit order.
Type of Bank Account Account Holder Name

S A V I N G S B A A L O N B E L I N GW I S E P ORT I A
Account No. Name of Bank
2 1 2 1 7 2 1 7 8 1 5 9 0 G UA RA N T Y T R U S T ( GH ) L T D
Branch Branch Code
N I A B RA N C H 2 3 0 1 1 2
I the undersigned, hereby authorise Enterprise Life Assurance Company to deduct the premium from my bank account or from any other account to Enterprise
Life Assurance Company I agree that my bankers withhold an amount equal to my premium, including any premium updates that may be due at all times to
ensure I am adequately covered under this policy
Mobile Wallet Details:
Mobile Wallet Number Mobile Network

Payer's signature Signed Date (YYYYMMDD)

2 0 2 4 0 7 04
INFLATION PROTECTOR: % (0,5,10,15,20,25,30)

11. STOP ORDER DETAILS (PREMIUM MANDATE)

Chief Paymaster / Employer

Pay Point / Compiling / Pay Office Initial Deduction end of (YYYYMMDD)Employee Number

GH 1 P 5 0 0 5 041 2 0 2 4 0 7 04
Initial Monthly Premium Policy Number
GHc INFLATION PROTECTOR: % (0,5,10,15,20,25,30)

I the undersigned hereby authorise the accountant to deduct the premium from my salary and remit the payment to Enterprise Life Assurance Company
Limited with effect from

OFFICER OTHER RANK SENIOR CIVILIAN JUNIOR CIVILIAN

STAFF CATEGORY:

Premium Payer
Signed Date (YYYYMMDD)
2 0 2 4 0 704

Employee's Accountant
Signed Date (YYYYMMDD)

2 0 2 4 0 704
LIFETIME NEEDS PLUS GH 3 V 0 9 9 6 708
Policy Number 5
12. PROPOSER DECLARATION
1. I apply for assurance with Enterprise Life's usual terms and conditions.

2. I understand that the answers to the above questions and statements and any documents required by the company shall be the basis of the contract.

3. I declare that the answers to the questions and statements whether in my own handwriting or not, are true and complete.

4. I understand and agree that benenfits under this policy may be adjusted or forfeited, at the discretion of the company, in the event that information
contained in this application form and any other declaration made by me is inaccurate.
5. I understand that Enterprise Life has the right to defer a claim on any nominated member covered under this policy until all requirements, as specified by
Enterprise Life, have been met.

6. I authorise the company to receive the premium, including any increase in premium arising on the anniversary of the issue day of the issue date of the
policy, by bankers order/salary deduction as indicated previously in the application. It is understood and agreed that the cover will commence on the
first day of the month following receipt by the company of the first premium.

7. I acknowledge receipt of the Policy Terms associated with my Policy application

8. I acknowledge that I have read and understood these declarations.

9. I hereby declare that I have personally checked all the information as given out in the form and confirm that all details such as names, addresses, date of
birth and bank details have correctly been spelled whether in my own handwriting or not and ammendments to this will require submission of evidence.

10. I further declare that the meaning and implications of premature cancellations have been explained to me and that I am fully aware of the possible
detrimental consequences of premature cancellations.

Signature of Life Assured

Signed Date (YYYYMMDD)

2 0 2 4 0 7 04

13. INTERMEDIARY DETAILS

Intermediary First Name Intermediary Surname
GM T - RH O D A N A A N U N O O
Agent Code Agent Branch Agent Contact Number
GH 3 F 0 0 0 4 270
I verify that the proposer, or the person acting on his/her behalf, recorded in this application confirmed his/her identify with an original acceptable document,
a true copy of which is attached.

BASIC EARNINGS: GHc