LOSS OF EMPLOYMENT INSURANCE SCHEME
EXPRESSION OF INTEREST FORM
Prospect's Email
Prospect's Name
Industry
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BANKING
TELECOM
OIL AND GAS
AVIATION
MANUFACTURING
Telephone
Company Location
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Abia
Abuja
Adamawa
Anambra
Akwa Ibom
Bauchi
Bayelsa
Benue
Borno
Cross River
Delta
Ebonyi
Enugu
Edo
Ekiti
Gombe
Imo
Jigawa
Kaduna
Kano
Katsina
Kebbi
Kogi
Kwara
Lagos
Nasarawa
Niger
Ogun
Ondo
Osun
Oyo
Plateau
Rivers
Sokoto
Taraba
Yobe
Zamfara
Company Name/ Name of Employer
Grade/Position
Department
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SUPPORT
OFFICER
SUPERVISOR
DEPUTY MANAGER
MANAGER
S.MANAGER
ASST. GENERAL MANAGER
DEPUTY GENERAL MANAGER
GENERAL MANAGER
DIRECTOR
CEO
Choose the appropriate depatment
Admin
HR
Marketing
Operations
I.T.
E-Business
Treasury
FinCon
Int. Con
Int. Audit
Others
Amount to be insured
Gross Monthly Salary
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School cert only
School cert with professional certification
Undergraduate cert only
Undergraduate cert with professional certification
1st Degree only
1st Degree with professional certification
2nd Degree only
2nd Degree with professional certification
3rd and Higher Degree (PhD) only
3rd and Higher Degree (PhD) with professional certification
Others
Qualification
Age
Sex
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Male
Female
Marital Status
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Single
Married
Divorced
Single Parent
Agent Code
Number of job changed within the last 5 years
Agent's Email
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