I hereby declare that all the information provided is in all respects correct and that no material facts have been suppressed or withheld. If such information has been provided on my behalf, I agree that this declaration and the answers given shall be the basis of the contract between myself and the company. I accept the usual terms and conditions prescribed by the company and endorsed on their policy. I further agree that as a result of my acceptance to take up the above cover. I am giving permission to my employer to deduct the premium from my salary (where applicable).

I understand that cover commences after being officially accepted by the company and the first premium has been paid.

By submitting this application, i agree to the terms and conditions of the policy.