Please enable JavaScript in your browser to complete this form.Payer Abroad - Step 1 of 3First Name *Last Name *Email *Phone *TitleMr.Mrs.Ms.MissDr.ID TypeInternational PassportDrivers LicenseID Expiry DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ID NumberResidential AddressRelationship With Policyholder ParentSiblingChildSpouseGuardianAcknowledgement as Payer, not InsuredI acknowledge that I am acting solely as the payer and not as the insured person under this policy.Consent to Data Processing – NDPA 2023I consent to the collection and processing of my personal data in accordance with the Nigerian Data Protection Act, 2023.NextFirst NameLast NameEmailPhoneTitleMr.Mrs.Ms.MissDr.ID TypeInternational PassportDrivers LicenseID Expiry DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ID NumberBVNResidential AddressInsured’s Details AcknowledgementI explicitly acknowledge that the details provided in this form are those of the insured person.Please note: The insured may be required to undergo medical tests if the sum assured or age threshold necessitates it PreviousNextSelect A Plan *Monthly - £3.00Quarterly - £9.00Bi-Annually - £18.00Annually - £36.00Test - £1.00Total£0.00PreviousSubmit
