Faraja - Enwealth Insurance

Premium Payer / Proposer Details

Tick Appropriately
Individual MemberWelfare SocietyOthers

Principal Member Details

Surname

Other Names

Date Of Birth

ID/Passport

Marital Status
MarriedSingleWidowedOthers

Phone Number

Email Address

Spouse Details

First Name

Surname

Date Of Birth

ID Number

Phone Number

Dependant's Details

Dependant's Details - Children, Parents & Parents In Law

First Name

Surname

Relationship

Date of Birth

Extra Child(ren)

Extra Child(ren) Of The Principal Member

First Name

Surname

Relationship

Date of Birth

Beneficiary

Beneficiary - [Person To Be Contacted In The Event Of Principal Death]

First Name

Surname

ID Number/Passport

Phone Number

Benefit Plan

Benefit Plan - (Kes)
PARTICIPANTS	OPTION A	OPTION B	OPTION C	OPTION D
PRINCIPAL MEMBER	50,000	100,000	250,000	500,000
SPOUSE (MAX 1)	50,000	100,000	250,000	500,000
CHILDREN (MAX 4)	50,000	100,000	250,000	500,000
PARENTS (MAX 2)	50,000	100,000	250,000	500,000
PARENTS IN LAW (MAX 2)	50,000	100,000	250,000	500,000
PREMIUM PAYABLE PER FAMILY (Select Option)	2,117	4,234	8,848	18,627
PREMIUM FOR ADDITIONAL CHILD (Select Option)	200	400	750	1,500

Payment Details

Amount Paid

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Introduced By

I declare to the best of my knowledge and belief that the particulars given above are true and correct. I uderstand and agree that any willful misrepresentation in this application will invalidate any benefit under this Policy and that I underatke to abide by the terms and conditions of the Policy.

Enwealth Faraja Benevolent Fund Application Form

Premium Payer / Proposer Details

Spouse Details

Dependants Details Children, Parents & Parents In Law

Extra Child(Ren) Of The Principal Member

Beneficiary Person To Be Contacted In The Event Of Principal Death

Benefit Plan - (Kes)

Payment Details

Premium Payer / Proposer Details

Principal Member Details

Spouse Details

Dependant's Details - Children, Parents & Parents In Law

Extra Child(ren) Of The Principal Member

Beneficiary - [Person To Be Contacted In The Event Of Principal Death]

Benefit Plan - (Kes)

Payment Details

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