Current Section A 1. CLAIMANT’S PERSONAL DETAILS 2. DETAILS OF OCCUPATION 3. DETAILS REGARDING IMPAIRMENT 4. PARTICULARS REGARDING INCOME 5. DETAILS REGARDING JOB DESCRIPTION Complete 1 of 7 Please insure that you fill in all the required fields in the below form Policy Number I (full name of claimant) hereby declare that I am the person assured under the scheme mentioned below. All the particulars given by this report are in every respect factual, true and correct and that no material information has been withheld nor has any relevant information regarding the circumstances been omitted. I hereby irrevocably authorize and request any doctor, other person or institution who may be in possession of, or later acquire, any information concerning my health, to disclose it to Botswana Life Insurance Limited. I also authorize Botswana Life Insurance Limited to release information concerning my health to all interested parties. Please note: The request for completion of this form in no way constitutes an admission of liability by Botswana Life Insurance Limited CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.