Application & Proposal

Stage 4 of 6 · Capture nominee, declarations and signature

Policyholder Details

Full Name

Kosal Vong

National ID

456987321789

Date of Birth

04 July 1981

Phone

+855 17 555 422

Nominee Details

Nominee Name

Relationship

Nominee NID

Share %

Plan Confirmation

Product

Manulife Group Credit Life

Coverage

$10,000

Premium

$18/mo

Term

5 years

Frequency

Monthly

Riders

None

Health Declaration

Has the customer been diagnosed with any chronic illness?

Has the customer been hospitalised in the last 2 years?

Does the customer use tobacco products regularly?

Document Checklist

National ID (front & back)
Selfie with NID
Proof of address
Loan documentation
Signed proposal form

RM Declaration & Signature

I, Sokha Chann (SP-00421), confirm I have personally explained the policy terms, verified the customer's identity, and witnessed the customer's consent.

RM Signature

Sign here

Submission will be logged to compliance audit trail.

Complete nominee, signature and declaration to submit