Life Insurance – Assessment of Demands and Needs

Policy Holder Details

Are you an existing MIB Customer?*

Yes
No

Please specify your Customer Number

Name*

First Last

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First Name

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Last Name

Company

ID Number

Date of Birth

Email Address*

Enter Email Confirm Email

Contact Phone Number*

Smoker/Non-Smoker

Smoker
Non-Smoker

Additional Policy Holders

Name	ID Number	Date of Birth	Smoker/Non-Smoker	Actions

There are no Additional Policy Holders.

Cover Information

Bank Required*

Is the policy required for a Bank Loan?

Yes
No

Amount of Loan*

Term of Loan repayment/number of years

Bank Providing Loan

Additional Details

Additional Comments

Terms Accept*

I have read and accept MIB's Client Terms of Business & Privacy Policy.*

I understand that by completing this form the data will be processed by MIB in line with GDPR and hereby consent that this data (including if needed sensitive data as defined in article 9 of GDPR) are used for the purposes of providing your insurance services.

I also understand that it is my responsibility to secure and hold the necessary consent from any employees, beneficiaries or other third parties direct or indirectly involved in the insurance proposal/arrangements and whose data will be processed by MIB and the providers of insurance and ancillary services.

Life Insurance – Assessment of Demands and Needs

Policy Holder Details

Cover Information

Additional Details

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