ENHANCED LOREFUNERAL MASTER PLAN

Single Married Divorced Widow

Date of Birth

Gender

Title

Age

First Names

Current Employer

Occupation

Client Number

Surname

Maiden Name and /

or former Surname

Residential Address

Postal

Address

Omang Number

Full Names

Next of Kin

Postal Address

Physical Address

Smoker

Cell

Res

Email

Next of Kin Telephone

Level of Education, eg Degree/ Diploma/ Certificate

Relationship

Work

Do you have an existing policy with Botswana Life?

SECTION A: POLICY OWNER / FIRST LIFE ASSURED

SECTION B: PREMIUM PAYER, IF OTHER THAN POLICY OWNER

Please complete in BLOCK LETTERS. Tick appropriate block unless otherwise indicated.

Your Reference

Application No.

Policy Number – –

Date of Birth

Gender

Title

First Names

Client Number

SurnameMaiden Name and /

or former Surname

Nature ofInsurable Interest

Omang Number

Cell Number

Work Number

Relationship of Policy Owner

Home

Email

Parent Spouse Business Partner

rehtO (Specify)

(Botswana Life Insurance Limited’s questionnaire on insurable interest may be required to clarify insurable interest).

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Passport Number OR

Passport Number RO

NB: Beneficiary must be over the age of 21 at the time of nomination

Client no. First Names Surname Gender Date of Birth ID Number/PassportNo. for Non-Citizens

Relationship to Policy Owner

% Share

MONTHLY PAYMENT BENEFICIARY

Client no. First Names Surname Gender Date of Birth ID Number/PassportNo. for Non-Citizens

Relationship to Policy Owner

% Share

SECTION E: BENEFICIARY (Death Benefit)

LUMP SUM BENEFICIARIES

SECTION C: PLAN DESCRIPTION

AUTHORISED SIGNATORY

Type of Account

Account Number

Town / City

Bank Name

Branch Code

Account Holder’sName

SECTION D: METHOD OF PAYMENT

BANK DETAILS

I/We hereby instruct and authorise Botswana Life to draw my/our account with the above-named bank (or any other branch to which I/We may transfer my/our account, the

amount necessary for payment for the initial monthly premium due, together with any other amounts due in respect of the above policy on the

day of each month commencing on the and continuing until further notice in writing from me/us. All such withdrawals from my/our account by

Botswana Life shall be treated as though they have been signed by me/us personally.

I/We understand that the withdrawals hereby authorised will be processed by computer through an electronic transfer service or computer media, and I/we also understand

that details of each withdrawal will be printed on my/our bank statement or accompanying voucher.

This instruction may be cancelled by me/us by giving Botswana Life 30 days notice in writing, sent by registered mail or delivered to the company’s office, but I/We understand

that I/We shall not be entitled to any refund of amounts which Botswana Life may have already withdrawn while this authority was in force if such amounts were legally owing

to Botswana Life, subject to the provisions of the Insurance Industry Act 1987.

Receipt by Botswana Life of this instruction shall be regarded as receipt thereof by my/our bank.

Monthly Quarterly Half year AnnuallyPREMIUM FREQUENCY

ESCALATION OPTIONS 0% 5% 10%

The date when the debit order takes effect

STRIKE DATE

Dependent on the date of acceptance by Botswana Life Insurance Limited and payment of the first contribution

COMMENCEMENT DATE

CashDebit Order Stop Order EFTMODE OF PAYMENTS

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SECTION F: ADDITIONAL LIFE ASSURED

Client no. First Names Surname Gender Date of Birth ID Number/Passport no. for non- Citizens

Relationship to Policy Owner

PARENT/PARENT IN LAW DETAILS

Client no. First Names Surname Gender Date of Birth ID Number/Passport no. Relationship to Policy Owner

EXTENDED FAMILY DETAILS

Client no. First Names Surname Gender Date of Birth ID Number/Passport no. for non- Citizens

Relationship to Policy Owner

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2. Botswana Life Insurance Limited standard conditions including those applicable to instant cover will apply to the contract and to any beneficiary nomination.

3. Any doctor, other person or institution is irrevocably authorised before and after the death of the life assured to disclose any information concerning his or her physical or mental health, including the results of any blood tests to Botswana Life Insurance Limited.

Signature(s) to be countersigned by legal guardian

if life assured is under the age of 18 or applicant is a minor.

I, THE LIFE ASSURED/OWNER ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THESE DECLARATIONS.

Date

Policy Owner / First Life Assured' Name Signature Date

SECTION I: INTERMEDIARY DETAILS

Intermediary Code Number Name(s) of Intermediary(s) Payment method Share % Primary Agent

I hereby declare that I have explained the policy to the proposer, the meaning and implications of replacements to the proposer and that I am fully aware of the possible detrimental consequences of the replacement of any insurance policy. I declare that all the information contained in this proposal was obtained from the proposer and was completed in his/her presence. I also declare that I have seen satisfactory evidence of proof of age of the proposer.

Intermediary Signature Date

4. Authorisation by account holder if payable by debit order. Botswana Life Insurance Limited may draw against the account in section C all amounts due in terms of this application. This authority is to remain in force until terminated by myself or Botswana Life Insurance Limited and I agree to advise Botswana Life Insurance Limited of any change in the account details given.

SECTION H: DECLARATION

State

State

1. Do you have an existing, or are you presently applying (excluding this application) for life insurance with this or any insurance company?

2. Is this application to replace the whole or part of any application to this or any office, or to replace all part of existing assurances with any office (whether replacement is to occur immediately or to replace an insurance policy discontinued within the past six months or to be discontinued within the next six months)?

IMPORTANT - REPLACEMENT OF ANY ASSURANCE IS NEARLY ALWAYS TO THE DISADVANTAGE OF THE HOLDER BECAUSE IT INVOLVES

DUPLICATION ON INITIAL COSTS CHARGED TO THE POLICY.

IF THE ANSWER TO QUESTIONS 1 OR 2 ARE YES, PLEASE PROVIDE FULL DETAILS IN THE SPACE BELOW.

Questions Name of Company Policy number Sum Assured (Pula)

It is agreed and declared that:

1. All information supplied in connection with this application, whether in my/our handwriting or not, is true and complete and will form the basis of the contract with Botswana Life Insurance Limited. All statements and declarations made in respect of an existing contract containing an option resulting in this application will form part of the basis of the new contract.

SECTION G: BENEFIT OPTIONS

Option

Member: Lump sum income (12 months)

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Spouse

Children (16- 21)

Children (0-16 years.exclu still borns)

Optional extended family/Parents

Still born: P2500, the pregnancy should be at least 28 weeks

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