Subscriber Details
Plan Details
Members Details
Agreement
Title
Please Select
Mr
Mrs
Miss
First Name *
Family Name *
Maiden Name
NIC/Passport *
Please select
NIC
Passport
NIC
Passport No
Attach Proof Of Identity *
Date of Birth *
Marital Status *
Please select
Single
Married
Divorced
Widow
Other
Street Number *
Street Name
City 1 *
City 2
Phone 1
Phone 2
Mobile 1 *
Mobile 2
Email
Attach Proof of Address
Source of Fund *
Please select
Pensioner
Savings
Salary/Self-Employed
Inheritance
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Regional *
Mauritius
Rodrigues
Plan Type *
Please select
Family
Single
Plan *
Please select
SERENITY ROD
COMFORT ROD
COMFORT
HINDU FUNERAL COVER
PRESTIGE
PSP
SERENITY
Age Group *
0-40
0-40
0-40
0-40
0-54 ROD
0-54 ROD
0-64
0-64
0-64
0-64
0-64
0-64
41-55
41-55
41-55
41-55
55-70
55-70
56-65
56-65
56-65
56-65
66-70
66-70
66-70
66-70
66-70
66-70 COMB
66-70 comb
66-70 COMB
66-70 comb
66-70 NEW
71+ PSP NEW
71+ PSP NEW
75+
Do you wish to combine your contract with any of your family members’ contract? *
No
Yes
Combined With *
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Member details and attachments
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Title
First Name
Last Name
Member NIC
Age
Principal?
Attachment
Action
Member No. 1
Member Title
Please Select
Mr
Mrs
Miss
First Name *
Last Name *
Choose Member NIC or Passport *
Please Select
NIC
Passport No
Data of Member NIC or Passport *
Member Age *
Principal *
Please Select
yes
no
Upload Member NIC *
Remove Member
Add Member
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Consent *
I (the applicant) agree that all the information that I have entered in this application about myself and the member(s) are true and correct.
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Submit