Fransajeunesse – Education Saving & Insurance Plan Application

Insurance & Savings

Gender

Applicant Title

First Name *

Family Name *

Father’s name *

Maiden name *

Date of birth *

Mobile Number *

Language

or Annual Premium (min. $300)

Target (Capital to be saved) *

Premium frequency *

Annual premium variation (2 to 10%) - Optional

Dependent gender

Dependent name *

Dependant Age at Maturity *

Dependant date of birth *

Annualized schooling amount (Between $500 and $6.000)

Annual variation on schooling amount (2 to 10%) - Optional *

Payment of schooling amount (quarterly or annually)

(*) Required fields