%@ Page Language="VB" %> <%@ Import Namespace="Unic.biz" %> Untitled Page  UNIC MORTGAGE PROTECTION PLAN:APPLICATION FORM Miss Mr. Mrs. Other Select an Option Female Male Select an Option Single Married Divorced Widowed Select an Option Annual One/off Please Note:Statements in this application constitute warranties, complete and accurate information must be given. When there is doubt as to the materiality of information, it must be disclosed in this application.Non-disclosure may lead to the Company repudiating the claim under this contract. I, a life to be assured,declare to the best of my knowledge and belief, that the information given in this proposal form is true and complete.I irrevocably authorize any doctor or other person(s) who may be in possesion of, or acquire, any information concerning my health to disclose such to the company (UNIC Life) for the purpose of assesing this application. I agree that if any answer has been written by any other person, on my behalf, such person(s) shall for that purpose be regarded as my agent and not the agent of the company. I declare that this proposal for assurance is made in good faith and shall be incorporated in and form part of the contract under the normal terms and conditions of UNIC Insurance Policy.