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First and Last Name*
Date of Birth (DD-MM-YY)*
Male / Female*
- Male
- Female
Smoker*
- Yes
- No
Email Address*
Contact Number*
Mobile Number
City*
Occupation*
Life Cover Amount*
Serious Illness Amount
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I/We have read, understood, and accept the privacy policy. I/We agree that Ease Insurance can provide services, information and advice to us relating to insurance. I/We authorise the collection and holding of our information, and disclosure of our details to any third parties that provide an operational service to Ease Insurance.