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BOSETU Legal Scheme
Membership Application Form
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Please enable JavaScript in your browser to complete this form.
1
Applicant's Details
2
Spouse Details
3
Children's Details
Applicant's Details
Title
*
Mr
Mrs
Ms
Dr
Professor
Marital Status
*
Married
Single
Divorced
Widow
Surname
*
Name
*
ID No (Omang)
*
Date of Birth
*
Email Address
*
Physical Address
*
Postal Address
*
Town/Villege
*
Telephone Phone (Work)
Cell phone
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Spouse Details
Spouse's Surname
Spouse's Name
Spouse's ID No (Omang)
Spouse's Date of Birth
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Children's Details
Children's Details Layout 1
Child's Name
Child's ID No/Birth Certificate No
Child's Date of Birth
Children's Details Layout 2
Child's Name
Child's ID No/Birth Certificate No
Child's Date of Birth
Children's Details Layout 3
Child's Name
Child's ID No/Birth Certificate No
Child's Date of Birth
Children's Details Layout 4
Child's Name
Child's ID No/Birth Certificate No
Child's Date of Birth
Children's Details Layout 5
Child's Name
Child's ID No/Birth Certificate No
Child's Date of Birth
Have you, your spouse or your children been convicted or charged with a criminal offence in the past three years?
*
No
Yes
If Yes, please elaborate
*
Are you at present have any matter, civil or criminal that is likely to give rise to litigation in the next three months?
*
No
Yes
If Yes, please elaborate
*
Declaration
DECLARATION
*
I declare that the statements and particulars in this proposal are, to the best of my knowledge and belief are true and complete, and this proposal shall form the basis of my legal insurance scheme.
Products
*
SILVER : For only P 42.50 per month and get cover of up to P42, 500.00 per annum.
GOLD : For only P 67.50 per month and get cover of up to P67, 500.00 per annum.
PLATINUM : For only P 97.50 per month and get cover of up to P97, 500.00 per annum.
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