<%@ 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.