PROPOSAL NO.

UG

LIFE ASSURANCE - PROPOSAL FORM

2nd & Ground Floor, Rwenzori Courts Nakasero Road. P.O Box 33953 Kampala, Uganda
Tel: 256-414-232337. Toll Free: 0800100120. Email: customerservicelife@[Link]

1 PROPOSER
Policy Number
The person by whom the assurance is to be effected

First Name: MELISSA Other Names BASALIRWA IGAGA

Gender Male Female ✔ Title
Relationship with insured SELF Telephone +256740013250

2 LIFE ASSURED
The person whose life is proposed for assurance

First Name: MELISSA Other Names BASALIRWA IGAGA

Gender Male Female ✔ Date of Birth 29/01/1998 Age Next Birthday 26
Occupation STUDENT Employer Annual Income N/A
Telephone 0740013250 Physical Address ARTISAN SQUARE HOMESEmail melissaigaga@[Link]
ID Type Passport National ID ✔ Driving Permit ID Number CF98013109UWDG
Nationality UGANDAN TIN No. Marital Status SINGLE

3 POLICY DETAILS
Detailed particulars of the policy
1
Type & Class of Policy Policy Term (Years) Payout Term
(If applicable)

Benefits Premium(Ugx/USD) Sum Assured

Basic Policy Premium
Accidental Death Benefit (Optional) 10,000,000 UGX

Permanent Total Disability (Optional) 10,000,000 UGX

Last Expense (Optional)

Critical Illness (Optional)
Training Levy (0.5% Premium)

4 PREMIUM PAYMENT METHODS

Details of how premium is to be paid and the currency to be used
300,000
Total initial Premium Paid with the proposal ____________________________________ Currency __________________________________
UGX
Frequency Mode of Payment

Annual Quartely Direct Debit Others (Cheque, Instruction)

Semi Annual ✔ Monthly Salary Deduction Mobile Money ✔

If Direct Debit: Bank _________________________ A/C Name______________________________ A/C No. ____________________________

If Salary Deduction: Employer _____________________________________________________ Payroll No._____________________________

Signature of life assured:___________________________________________________

5 HEALTH FOR LIFE ASSURED
Questions to ascertain and understand your health condition

a) Are you in all aspects in good health? Yes ✔ No

If No, give details _____________________________________________________________________________________________________

10 SEPTEMBER 2023
b) When and why was the doctor last consulted?______________________________________________________________________________
Give details treatment_________________________________________________________________________________________________
MALARIA TEST, URINALYSIS, BLOOD SUGAR TEST

c) Are you currently taking treatment or medication of any kind? Yes ✔ No

VENTOLIN
If yes, give medication details____________________________________________________________________________________________

e) Have you ever suffered from any illness or disease during the last five years for which you required medical attention?
ASTHMA
Illness _____________________________________ N/A
Date ____________________________________ N/A
Duration ________________________
163CM
d) Height in cm/ft_________________________________ 95
Weight in Kgs ___________________________

f) Have you ever had, been tested for, received treatment or counseling from medical professionals for; or been told you have
(Tick appropriate and give details where applicable)
i) Diziness, fainting, convulsions, epilepsy, paralysis, stroke,severe headaches Yes No ✔

ii) Depression, anxiety, alzheimer’s disease, mental or nervous disorder Yes No ✔

iii) Shortness of breath, bronchitis, emphysema, asthma, pleurisy, pneumonia, tuberclosis or persistent cough Yes ✔ No
iv) Chest pain, angina, irregular heart beat, high blood pressure, heart attack, congestive
heart failure or coronary heart artery disease Yes No ✔

v) Heart murmur, heart valve disorder, oedema or the heart or blood vessels Yes No ✔

vi) Ulcer, intestinal bleeding, colitis, ulcerative colitis, cohn’s disease, jaundice, hernia, diarrhea, hepatitis or any
disorder of the stomach, intestines, spleen, liver or rectum Yes No ✔

vii) Diabetes, high blood sugar or sugar in the urine Yes No ✔

viii) Blood protein in your urine, any disorder of the kidneys, bladder, prostate or urinary system Yes No ✔

ix) Venereal disease or any disorder of the reproductive system Yes No ✔

x) Thyroid, thymus, pituitary or lymph gland disorder goiter Yes No ✔

xi) Cancer, sarcoidosis, tumor or any abnormal growth Yes No ✔

xii) Back pain, arithritis, muscular dystrophy or any disorder of the muscles, bones or joints Yes No ✔

xiii) Multiple sclerosis, parkinson’s disease or any disorder of the brain or spinal cord Yes No ✔

xiv) Hemophilia, sickle cells anemia, anemia or any disorder of the blood Yes No ✔

xv) Any disease not mentioned above Yes No ✔

Please provide complete details of all ‘yes’ answers above (including details of treatment, medical institution where treated and name
of treating doctor. Additional sheets, information or reports maybe attached to this form where required.
I HAVE ASTHMA, I GET INHALERS FROM AAR NTINDA CLINIC.

g) Have you ever had or been advised to have blood test for HIV related condition or immunological disorder Yes No
If yes, give details of status: __________________________________________________________________
h) Have you ever received a blood transfusion or been refused as a blood donor within the last 5 years? Yes No
If yes, give details : _________________________________________________________________________
i) Have you ever had an X-ray, electocardiogram and any other serious medical tests? Yes No
If yes, give details : _________________________________________________________________________
j) FOR FEMALES ONLY | Are you currently pregnant? Yes No
If yes, give number of weeks : ________________________________________________________________

6 LIFESTYLE AND FAMILY HISTORY

k) Are there any unusually harzadous circumstances which might affect this assurance? Eg: dangerous sports, Yes No
service in armed forces, aviation. If yes, give details : ____________________________________________
l) Do you use tobacco and other habit forming drugs? Yes No
If yes, state type and average daily use :________________________________________________________
m) Do you consume alcohol or being treated for alcoholism? Yes No
If yes, give details and daily consumption : _____________________________________________________

Signature of life assured:___________________________________________________

n) Has any of you family members ever suffered from and/died from diabetes, heart, cancer or mental illness? Yes No ✔

If yes, give details: _________________________________________________________________________

7 PREVIOUS INSURANCE HISTORY

o) Is your life currently being proposed for life assurance elsewhere? Yes No ✔
If yes, Which company(s) and type of policy(s)______________________________________________________________________________

8 FREE COVER LIMIT BENEFITS SCALE

We have two cover limit options and these are dependant on your sum assured. Please tick where applicable.

✔ Sum Assured: 0-40 Million

Benefits shall be paid on a sliding scale in the event of death (natural causes only) within the first twelve (12) months as per the scale below;

Period (in months) Benefits payable as % of Sum Assured

0 to less than 3 0%
3 to less than 6 25%
6 to less than 9 50%
9 to less than 12 75%
After 12 months 100%

Sum Assured: 40-80 Million

Benefits shall be paid on a sliding scale in the event of death (natural causes only) within the first twelve (24) months as per the scale below;

Period (in months) Benefits payable as % of Sum Assured

0 to less than 6 0%
6 to less than 12 25%
12 to less than 18 50%
18 to less than 24 75%
After 24 months 100%

9 COVID-19 DECLARATION
Can you kindly whether you have you experienced Covid-19 like symptoms, or been exposed to a person diagnosed with Covid-19 or have you
in the last 4 weeks travelled abroad or do you plan to travel abroad in the next 4 weeks.

Have you:
a) Experienced any ‘flu’ like symptoms (e.g. Fever, dry cough, fatigue) Yes No ✔

b) Been exposed to a person diagnosed with Covid-19 Yes No ✔

c) Travelled to any COVID-19 affected country in the last 4 weeks Yes No ✔

d) Been advised to self-isolate, or are in quarantine either because of your travel or symptoms? Yes No ✔

e) Had Covid-19 & recovered? (If so please provide dates of diagnosis and recovery as well as records) Yes No ✔

Signature of life assured:___________________________________________________

8 BENEFICIARY INFORMATION
Detailed information about your preferred beneficiaries

A) Main Beneficiaries
Beneficiary Name Relationship Date of Birth Contact % share
PETER JAMES NGOBI IGAGA FATHER 24/03/1976 +256752363536 50
ALICE MMBOGA LIROVA MOTHER 18/09/1969 +18039202313 50

NB: % share should equal 100%

B) Contingent Beneficiaries
Beneficiary Name Relationship Date of Birth Contact

9 DECLARATIONS AND AUTHORIZATIONS

Please read through and understand

MELISSA BASALIRWA IGAGA

I_______________________________________________________________________________________________declare that the information provided in
this application whether in my own hand or not is complete and true to the best of my knowledge and belief, and that it shall form
basis for this policy. I will advise ICEA LION Life Assurance Company Uganda Limited in writing if there are any changes to the
information given in this form before the policy issue date.

1) This application for insurance is hereby made to ICEA LION LIFE ASSURANCE COMPANY UGANDA LIMITED which is duly
authorised to transact insurance business in Uganda.
2) The answers in this application are complete and true to the best of my/our knowledge.
3) The statements made in this application and in any other documentation submitted in connection with this application form
the basis of the policy applied for and shall constitute all representations made as a basis for the said policy.
4) No agent has the authority to waive a question in the application, modify the application or bind the company by making any
promise or representation or by giving or receiving any information.
5) Information regarding your insurability will be treated as confidential. The comapany or its reinsurers may, however release
information in this file to other life insurance companies to whomo you may apply for life or health insurance, or to whom a
claim for benefits may be submitted.
6) ICEA LION Life Assurance Company Uganda Limited’s preferred modes of premium payments are Mobile Money, Banker’s
Order, Direct Debit or Salary Deductions by Employer. For any payments made in cash, it will be the payer’s responsibility to
ensure that he/she receives an official receipt for each cash payment made. Consequently ICEA LION Life Assurance Company
Uganda Limited will not be liable for any cash payments except where an official company receipt has been issued.

N.B: 1. Cancellation of this application prior to underwriting will attract an administrative charge of Ugx. 10,000.
2. For proposals cancelled after medical tests, the proposer shall bear the medical costs.

12/09/2023
Signature of life assured:___________________________________________________ Date ____________________________________________
MELISSA BASALIRWA IGAGA 12/09/2023
Name of Proposer: _________________________________________________ Signature ______________________ Date ________________

10 INTERMEDIARY DETAILS
Detailed information about the agent responsible for servicing the life assured

A) Agent
Name Branch Unit Signature Date

B) Unit Leader
Name Signature Date
Date