Family Indemnity Plan (FIP) Member Enrolment Form

Have you previously had a Family Indemnity Plan certificate?

Yes

No

Are you or any person(s) who will be listed below presently covered under another Family Indemnity Plan certificate?

Yes

No

Personal Information

First Name

Middle Name

Last Name

Membership Number

Date of Birth

Gender

Male

Female

Email Address

Address

Address Line 1

Address Line 2

City/Town/Village

Country

Main Telephone Number

Organisation

Indentification Information

Identification Type

Driver's Permit

National ID

Passport

Identification Number

Country of Birth

Beneficiary Information

Please complete a Designation of Beneficiary Form if you are the only person on this form or if all insureds are minors.

Beneficiary 1

First Name

Middle Name

Last Name

Gender

Male

Female

Date of Birth

Relationship to Member

Gender

Male

Female

Date of Birth

Relationship to Member

Beneficiary 2

First Name

Middle Name

Last Name

Gender

Male

Female

Date of Birth

Relationship to Member

Beneficiary 3

First Name

Middle Name

Last Name

Gender

Male

Female

Date of Birth

Relationship to Member

Beneficiary 4

First Name

Middle Name

Last Name

Gender

Male

Female

Date of Birth

Relationship to Member

Beneficiary 5

First Name

Middle Name

Last Name

Gender

Male

Female

Date of Birth

Relationship to Member

Schedule Information

Premium Schedule for the Family Indemnity (FIP) Enrolment

Select a Plan

$10,000 - Individual Benefit / $52.80 - Monthly Premium

$15,000 - Individual Benefit / $79.20 - Monthly Premium

$20,000 - Individual Benefit / $105.60 - Monthly Premium

$30,000 - Individual Benefit / $158.40 - Monthly Premium

$40,000 - Individual Benefit / $211.20 - Monthly Premium

$65,000 - Individual Benefit / $343.20 - Monthly Premium

$100,000 - Individual Benefit / $528.00 - Monthly Premium

Premium Schedule for the Family Indemnity (FIP): Critial Illness Rider Enrolment

Option 1: Coverage of $50,000

Monthly Premium by Age Bands

18-34 - $35.00

35-44 - $71.50

45-54 - $149.00

55-59 - $244.50

Option 1: Coverage of $100,000

Monthly Premium by Age Bands

18-34 - $70.00

35-44 - $143.00

45-54 - $298.00

55-59 - $449.00

NB: The monthly premium payable for the Primary Insured is based on the issue age and the selected coverage limit, maximum age of entry is 59 years. The premium amount payable for each coverage amount applied for remains the same for that coverage amount throughout the lifetime of the certificate for the Primary Insured, subject to any changes arising from annual premium rate reviews.

Have you ever been diagnosed with any of the following: Cancer, Heart Attack, Stroke, Paralysis OR Major Burns?

Yes

No

If yes, please indicate the details

Have you received, in the last 5 years, any medical attention, medical advice, surgical treatment or prescribed over the counter medication.

Yes

No

If yes, please indicate the details

Family Indemnity Plan (FIP) Member Enrolment Form

Personal Information

Indentification Information

Beneficiary Information

Beneficiary 1

Beneficiary 2

Beneficiary 3

Beneficiary 4

Beneficiary 5

Schedule Information

Premium Schedule for the Family Indemnity (FIP) Enrolment

Premium Schedule for the Family Indemnity (FIP): Critial Illness Rider Enrolment

Option 1: Coverage of $50,000

Option 1: Coverage of $100,000

Membership

Address

Telephone

Fax

Email

Tools & Support

Membership

Family Indemnity Plan (FIP) Member Enrolment Form

Personal Information

Indentification Information

Beneficiary Information

Beneficiary 1

Beneficiary 2

Beneficiary 3

Beneficiary 4

Beneficiary 5

Schedule Information

Premium Schedule for the Family Indemnity (FIP) Enrolment

Premium Schedule for the Family Indemnity (FIP): Critial Illness Rider Enrolment

Option 1: Coverage of $50,000

Option 1: Coverage of $100,000

Membership

Address

Telephone

Fax

Email

Join the conversation

Follow us

Tools & Support

Membership