No. 21 Independence Avenue,
PMB CT 455, Cantonments, Accra - Ghana
[+233] 30 2235437/2235434-5
HOME CARE PLAN REGISTRATION FORM
Unity reference #:
Next of Kin
Full Name of Next of Kin:
Next of Kin's Address:
Next of Kin's Phone #:
Date of birth (mm/dd/yyyy):
Is this member in good health? :
Please provide Health information :
Had the insured had any illness, surgical operation, met with any accident or undergone any special operation?:
If Yes please give details :
Terms & Conditions
I, the undersigned, whose life is proposed for assurance declare to the best of my knowledge and belief that, all the answers provided to the questions and the statements I have made whether in my own handwriting or not are true and complete and I agree that, this proposal together shall form the basis of the contract.
I understand that, any medical history known to me that is not disclosed about any of my beneficiaries may invalidate the policy.
By this declaration, I authorize Vanguard Life Assurance Company Ltd. to receive premiums and to obtain any information it deems relevant to this proposal from any person. The Payment Facilitator of the invoice is not liable for any breach of this policy.
By signing this declaration, I confirm that, I have read and understood these declarations and acknowledge receipt of the Policy Terms and Conditions attached.