Lagelu Grammar School 1984 Set – Group Life Insurance Registration

Personal Identity Health Beneficiary Declaration

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Personal Details

Step 1 of 5 · Your basic information

Full Name *

Please enter your full name.

Date of Birth *

You must be between 55 and 63 years old.

Please enter a valid date of birth within the eligible age range.

Phone Number *

Nigerian mobile number (11 digits starting with 0).

Please enter a valid 11-digit Nigerian phone number.

Email Address (optional)

Please enter a valid email address.

Home Address *

Please enter your home address.

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Identity Verification

Step 2 of 5 · KYC information

NIN – National Identification Number *

Your 11-digit National Identification Number.

Please enter your valid 11-digit NIN.

Alternative ID Type *

Please select an alternative ID type.

Alternative ID Number *

Please enter the ID number.

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Health Declaration

Step 3 of 5 · Simple Yes / No questions

Do you have any existing medical condition? *

✓ Yes

✗ No

Please select an option.

Please describe your medical condition(s): *

Please provide details about your medical condition.

Are you a smoker? *

✓ Yes

✗ No

Please select an option.

Are you currently on any regular medication? *

✓ Yes

✗ No

Please select an option.

Please list your medication(s): *

Please list your medications.

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Beneficiary Details

Step 4 of 5 · Who should receive your benefit

Beneficiary Full Name *

Please enter the beneficiary's full name.

Relationship to Member *

Please select the relationship.

Beneficiary Phone Number *

Nigerian mobile number (11 digits starting with 0).

Please enter a valid 11-digit phone number.

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Declaration & Payment Reference

Step 5 of 5 · Final confirmation

Bank Transfer Reference / Name Used *

Enter the name or reference used when making the bank transfer.

Please enter your payment reference or name used.

I confirm that all information provided is accurate and complete. I consent to this data being processed and shared with the insurance provider for the purpose of this Group Life Insurance scheme.

✓

Registration Submitted!

Thank you. Your details have been received successfully.
Please save your Member ID below.

Member ID:

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Lagelu Grammar School1984 Set

Personal Details

Identity Verification

Health Declaration

Beneficiary Details

Declaration & Payment Reference

Registration Submitted!

Lagelu Grammar School
1984 Set