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Company

Name *

Surname *

Contact Number *

Email: *

Life Cover Amount (N$100 000 minimum) *

Dread Disease Cover Amount (N$100 000 minimum) *

Disability Cover Amount (N$100 000 minimum) *

Date of Birth (dd-mm-yyyy) *

Age *

Dread disease *

Yes No

Disability *

Yes No

Premium back Option *

Yes No

Qualification *

4 Year degree 3 Year degree Matric Grade 10 /std 8

Height (cm) *

Weight (Kg) *

Cholesterol - If unsure please select 6 *

0 1 2 3 4 5 6 7 8 9 10

Blood Pressure *

120-150 151-155 156-160 161-165 166-170

Smoker *

Yes No

AIDS *

Yes No

Liver Function *

Low Normal High

reCAPTCHA *

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