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Group Scheme Request for Quotation
Requested By:
Group Name:
Contact Person:
Physical Address:
Postal Address:
Postal Code:
Postal Code:
Same as physical address
Tel Number:
Cel Number:
Fax Number:
Email Address:
Group Details
Is this an Existing Scheme
If you answered yes to the above question:
Please provide the following key pieces of information in order for Union Life to evaluate of the scheme and to provide rates.

What type of Scheme is this?
Who will be responsible for the payment of the premiums?
What is current claims paid vs premium income ratio?
Please select appropriate ratio:
The following member information is available.
Please select of appropriate:

What shoud the duration of cover be?
Number of Members:
(Please provide proof to verify number of members)
Normal Retirement Age:
Maximum entry age of lives to be insured:
What is the Company/Group Profile
(Give a brief description of the nature of your business e.g. Chemical,Mining,Blasting etc.)
Geographic Location:
What is the Current and Proposed Benefit Structure?
Current Benefit Structure:
Proposed Benefit Structure:
Current Premium Rate:
Proposed Premium Rate:
Do you wish to cover Extended Family Members?
Current Benefit Structure:
Proposed Benefit Structure:
Please indicate if any auxiliry benefits are requiered

I, A duly authorised person, hereby request a quotation for a Group Scheme based on the above information, which is true to the best of by knowledge.
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