Please complete the form below to sign up for Muditule
Step 1.
Your Details
Proposer phone number #:
Proposer NRC*:
Address*:
Town*:
MAIN NRC*:
Phone*:
Step 2.
Tell us about yourself
Occupation*
Place of work*
Beneficiary Full Name*
Beneficiary Relationship
Payment Option
Spouse Name
Spouse Gender
Spouse Date of Birth
Step 3.
Additional Assured Members
Assured name 1
Date of birth 1
Assured Gender 1
Assured Relationship 1
Assured name 2
Date of birth 2
Assured Gender 2
Assured Relationship 2
Assured name 3
Date of birth 3
Assured Gender 3
Assured Relationship 3
Assured name 4
Date of birth 4
Assured Gender 4
Assured Relationship 4
Assured name 5
Date of birth 5
Assured Gender 5
Assured Relationship 5
Assured name 6
Date of birth 6
Assured Gender 6
Assured Relationship 6
Assured name 7
Date of birth 7
Assured Gender 7
Assured Relationship 7
Assured name 8
Date of birth 8
Assured Gender 8
Assured Relationship 8
Assured name 9
Date of birth 9
Assured Gender 9
Assured Relationship 9
Assured name 10
Date of birth 10
Assured Gender 10
Assured Relationship 10