Easisure Financial Services - Insurance Simplified

Personal Information

Please provide your basic details

First Name *

Last Name *

Email Address *

Phone Number *

National ID Number *

Date of Birth *

Gender *

Marital Status *

Address Information

Where are you located?

Street Address *

City *

Province *

Postal Code

Insurance Requirements

Tell us about your insurance needs

Type of Insurance *

Estimated Coverage Amount (USD) *

Preferred Start Date *

Policy Duration *

Specific Details

Provide details relevant to your insurance type (fill in what applies to you)

Vehicle Details (For Car Insurance)

Property Details (For Home Insurance)

Business Details (For Business Insurance)

Health Information (For Health/Life Insurance)

Employment & Income

Help us understand your financial situation

Occupation/Job Title *

Employer Name

Monthly Income Range (USD) *

Years at Current Job

Beneficiary Information

Who should receive benefits? (Required for Life Insurance)

Primary Beneficiary

Full Name

Relationship

Phone Number

National ID Number

Alternate Beneficiary (Optional)

Full Name

Relationship

Medical & Health History

For Health and Life Insurance applications

Chronic Conditions

Current Medications

Previous Surgeries/Hospitalizations

Family Medical History

Insurance History

Tell us about your previous insurance experience

Do you have existing insurance? *

Yes

No

Current/Previous Insurance Provider

Have you made any insurance claims in the past 5 years?

Yes

No

Claims Details (if applicable)

Reason for Switching/Getting Insurance

Policy Number *

Risk Assessment

Help us assess your risk profile

Do you have any criminal record?

Yes

No

Driving License Type (For Car Insurance)

Years of Driving Experience

Number of Accidents in Last 5 Years

Security Measures in Place

Additional Coverage & Preferences

Customize your insurance package

Additional Coverage Options (select all that apply)

Additional Notes or Special Requirements

How Did You Hear About Us?

Preferred Contact Method *

Preferred Contact Time

Payment Preferences

How would you like to pay?

Payment Frequency *

Preferred Payment Method *

Terms & Consent

Please review and accept our terms

I agree to the Terms and Conditions and Privacy Policy. I confirm that all information provided is accurate and complete to the best of my knowledge. *

I authorize Easisure Financial Services to conduct credit checks and verify the information provided in this application.

I would like to receive marketing communications, special offers, and updates from Easisure Financial Services via email, SMS, and WhatsApp.

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