To the best of your knowledge, are you in good health? YES/NO if no, please explain
I/We the person/s by whom the fund is to be affected, declare that to the best of my knowledge and belief. I/We am/are in good health, free from diseases and disability or symptoms thereof. I/We agree that the foregoing and the UCS Sacco. I/We also understand that no natural death claim shall be payable during the first 6 months from the effective date.