Generator

Complete Application Form

Fill out the form or call +256417726526 for assistance!

Select Service(s)

Childstar Plan

Premium Payer Details

First Name

Surname

Title

Proof Of Identification

Marital Status

Date of Birth

Age

Nationality

ID Country

ID Number

Gender

Citizenship

Residence

Contact Details

Mobile(Tel)

Preferred Postal Address

PO Box

Town/Street

Building

Life Assured USA Address

Street

Town/City

Region/State

ZIP Code

Tax Residency Declaration

Tax Country

Tax Number

USA Tax Number

Employment Details

Employer

Employmee Number

Employment Date

Occupation

Department

Education Level

Salary Frequency

Salary Pay Day

Basic Earnings (Per Month)

Net Earnings (Per Month)

Employment

Policy Holder Details

Premium payer different from Policy holder (If YES leave the section Blank)

First Names

Surname

Date of Birth

Age

Gender

Title

Marital Status

Proof Of Identification

Nationality

ID Number

ID Country

Citizenship

Residence

Policy Holder Life Cover

Cover Level

Term (Yrs)

Savings Premium

Contigent Beneficiary

First Name

Surname

Date of Birth

Gender

Title

Relationship

% Split

Mobile

Beneficiaries

First Name

Surname

Date of Birth

Gender

Title

Relationship

% Split

Mobile

Spouse is Guardian

Guardian full names

Guardian Birth Date

Gender

Mobile

+ Add Beneficiary

Payment Details

Payment Method

Payment Frequency

Inflation Protector Benefit

Total Premium (M)

Start Date

USE THIS SECTION IF YOU WISH TO PAY NOW WITH VISA CARDS

First Name

Last Name

Address

City

Country

Card Number

Expiration Date

CV Code

Name on Card

Payment Purpose

Payment Details

Success!

Thank You for choosing Sanlam Life Insurance.
Application Form will be sent to your Email ID .

Download PDF
Create New Form
Return Home

Complete Application Form

Select Service(s)

Premium Payer Details

Contact Details

Preferred Postal Address

Life Assured USA Address

Tax Residency Declaration

Employment Details

Policy Holder Details

Policy Holder Life Cover

Spouse

Contigent Beneficiary

Beneficiaries

Statement of Health of life to be Assured

Payment Details

USE THIS SECTION IF YOU WISH TO PAY NOW WITH VISA CARDS

Upload National ID or Passport or Driver's License

Success!

Complete Application Form

Select Service(s)

Premium Payer Details

Contact Details

Preferred Postal Address

Life Assured USA Address

Tax Residency Declaration

Employment Details

Policy Holder Details

Policy Holder Life Cover

Spouse

Contigent Beneficiary

Beneficiaries

Statement of Health of life to be Assured

Payment Details

*******USE THIS SECTION IF YOU WISH TO PAY NOW WITH VISA CARDS*******

Upload National ID or Passport or Driver's License

Success!

USE THIS SECTION IF YOU WISH TO PAY NOW WITH VISA CARDS