PROPOSER DETAILS

BENEFICIARY FOR OWNERSHIP:

(Not automatically covered unless details are included in section D)

FUNERAL BENEFIT PLAN:

(Tick where appropriate)

Please give details of everyone to be covered, including self, your family/other dependents.

Declaration

I, the undersigned, hereby declare that the information provided by me and required of me on this application is true and correct and that I understand the product terms and conditions.