Step 1 of 5

Personal Details

Fields marked with * are required

First Name *

Last Name *

Other Names

Date of Birth *

Gender *

Marital Status *

Phone Number *

Village *

Traditional Authority *

District *

Permanent Address *

Contact & Employment

Email *

Alternative Phone *

ID Type *

ID Number *

Employer Name *

Workstation *

Job Title *

Employment Number *

Shares

Leave blank to use default: K10,000

Deposits

Leave blank to use default: K3,000

Welfare Fund

Leave blank to use default: K850

Note: Minimum Share: K10,000 | Deposits: K3,000 | Welfare Fund: K850 | Services Fees: K2,550

Step 2 of 5

Nominated Kins

If more than 1 kin, please allocate the percentage. Fields marked with * are required.

First Kin *

First Name *

Last Name *

Date of Birth *

Gender *

Relationship *

Allocation % *

Second Kin (Optional)

First Name

Last Name

Date of Birth

Gender

Relationship

Allocation %

Auto-calculated from first kin percentage

Step 3 of 5

Premiums and Cover Options

The member will be contributing a premium of MK500 only per month and will be able to cover up to 7 persons. This fee is non-refundable.

Assured Person	Cover Amount
Member	MK500,000
Spouse	MK250,000
Children	MK150,000
Parents	MK50,000

Declared Family Members (Optional)

You can declare up to 4 family members.

Beneficiaries

Main Beneficiary *

Fields marked with * are required

Full Name *

Date of Birth *

Relationship *

Phone Number *

Contingent Beneficiary *

Fields marked with * are required

Full Name *

Date of Birth *

Relationship *

Phone Number *

Note: There is a 6 months waiting period in case of natural death from the date of the first premium

Declaration by the Proposer and Life Assured

To the best of your knowledge, are you in good health? *

YES NO

I/We the person/s by whom the Assurance is to be effected, declare that to the best of my knowledge and belief: I/We am/are in good health, free from disease and disability or symptoms thereof. I/We agree that the foregoing answers and this declaration and answers to the questions put shall be the basis of contract between me/us and Co-operatives Life Assurance. I/We also understand that no natural death claim shall be payable during the first 30 DAYS from the effective date.

Acknowledgement

I hereby make Application for Membership, Funeral cover and agreed to conform to the Bye-Laws and any Amendments thereof

Step 4 of 5

File Uploads

Fields marked with * are required

ID Document Upload (Front) *

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