Personal Accident Proposal

Please make sure you read every question carefully. If you don’t answer the questions correctly and accurately, your policy may be cancelled, or your claim rejected or not fully paid.

Your Details
Persons to Cover
Consent

Title *
First Name *	Middle Name(s) Enter your middle name(s) if any
Last Name *
Date Of Birth * Day Month Year

Address Line 1 *	Address Line 2
Address Line 3	Post/Zip Code

Telephone	Cellphone
Email *	Occupation Enter your professional occupation
Period Of Insurance
Start date of cover: * Day Month Year	Period of cover *
Do you require restricted cover? * yes no

We are regulated by the following authorities

The Reserve Bank of Zimbabwe
Insurance and Pensions Commission of Zimbabwe
Ministry of Health

Where to Find Us: 14 Steven Drive, Msasa, Harare, Zimbabwe Tel : +263(4) 480817 Email : customerservices@zimselector.com

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Personal Accident Proposal

Period Of Insurance