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                                                             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

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.