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Proposer

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Please upload your passport photo(Max file size: 2MB)
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Contact address must contain House No. and street name (i.e 7, Kufo street)
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Area Name (i.e Victoria Island)
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Identification Details

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e.g Driver's License, National ID Card, International Passport (Max file size: 2MB)

Policy Details

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Details of Beneficiary

Please provide the following details of the beneficiaries in a schedule in PDF:

1. Primary Beneficiary : Fullname, DOB, Relationship & Phone
2. Contingent Beneficiary : Fullname, DOB, Relationship & Phone

Download sample template
A PDF document or photo containing a list of beneficiaries to be covered (Max file size: 2MB)

EXCEPT AS OTHERWISE DIRECTED

I. The proceeds are to be divided equally among all persons who are named as Primary Beneficiary and who survive the Life Assured, but if none survive, equally among all persons who are named as Contingent Beneficiary and who survive Assured.

II. The right to change the beneficiary is reserved.

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Payment Method

 
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Please take a picture of your signature and upload (Max file size: 2MB)

Declarations

I, the Life Assured, do hereby declare that all the foregoing answers are true, that I have not concealed nor withheld anything with which the assurer should be acquainted with in order to assess my eligibility for assurance.
I agree that these and all statements I have made or shall make to the Assurer or to its medical examiner(s) in connection with this or previous proposal(s) shall be the basis of this contract.
I irrevocably authorize and request any Doctor or other person who may be in possession of, or hereafter acquire, any information concerning my health up to the present time to disclose such information to the Assurer. I agree that this authority and request shall remain in force after from now and even after my death

Restrictions – War and Kindred Risks

It is agreed and expressly understood that should the death of the Life Assured occur directly or indirectly from and his / her engaging in or taking part in riot, strike, civil commotion, mutiny insurrection, war (whether war be declared or not), or any act incidental thereto, the total amount payable under this policy shall be limited to the total contributions made together with the total interest accrued thereon.

The Assurer shall not recognize any claim arising from any medical impairment or condition of a Life Assured which occurred or which was diagnosed prior to commencement of the term of assurance under this Policy, or within six (6) months of such commencement.



Kindly ensure all payments are made directly into AXA Mansard's designated corporate account(s). All cash payments MUST be made in person, as the company shall not be held liable for cash payments made to/through other third parties apart from NAICOM licensed Insurance brokers.

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Non-Medical Questionnaire

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In the case of female lives only

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Terms and Conditions

"I, the Life Assured declare that over the last 10 years, I have not had the symptoms of or been diagnosed with and I’m not under current investigation or intending to have investigation for a heart, lung or circulatory disorder, high blood pressure, stroke, diabetes, kidney, liver, neurological disorders, HIV infection or AIDS, Hepatitis B or C, cancer, tumour/lump/polyps/or growth of any kind and during the past 2 years I was not hospitalised for more than 7 consecutive days."

AXA Mansard is joining the rest of the world in being environmentally responsible. We invite you to join us in this cause by using only the electronic copy of your policy document which will be sent to your registered email address. You can also access it from your online account at www.axamansard.com or on MyAXA Plus App (available on Play Store or IOS Store).

Should you still want to receive a hard copy of your document in addition to the electronic copy, please place a request with your account officer or send an email to insure@axamansard.com. Your choice to decline making such request will serve to indicate that you do not agree to partner with us to preserve the environment.

By clicking "Submit" you declare that you consent to the data processing practices described in our data privacy policy https://www.axamansard.com/privacy-policy/ and consent to the collection, processing use and transfer of your Personal Data by the Company and its subsidiaries

 

**The liability of the Company does not commence until this Proposal has been accepted by the Company

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