TRAVEL INSURANCE PROPOSAL

07004347746

09122222200

wecare@heirsgeneralinsurance.com

TRAVEL INSURANCE PROPOSAL FORM

IMPORTANT INFORMATION

“An Insurance Agent who assists an applicant to complete application or proposal form for insurance shall be deemed to have done so as the agent of the applicant – Section 54 (2) Insurance Act, 2003”.

DO NOT PAY CASH TO ANY AGENT. ONLY PAY INTO THE AUTHORISED COMPANY ACCOUNT.

FOR PERSONAL DETAILS

NAME OF THE ASSURED

Surname: (*)

First Name: (*)

Middle Name:

Mobile Number: (*)

Mobile Number 2:

Email Address: (*)

Contact Address: (*)

Office Address:

BVN: (*)

Gender: (*)

Date of Birth: (*)

Nationality: (*)

State: (*)
[select* state "" "Abia" "Adamawa" "Akwa Ibom" "Anambra" "Bauchi" "Bayelsa" "Benue" "Borno" "Cross River" "Delta" "Ebonyi" "Edo" "Ekiti" "Enugu" "FCT" "Gombe" "Imo" "Jigawa" "Kaduna" "Kano" "Katsina" "Kebbi" "Kogi" "Kwara" "Lagos" "Nasarawa" "Niger" "Ogun" "Ondo" "Osun" "Oyo" "Plateau" "Rivers" "Sokoto" "Taraba" "Yobe" Zamfara"]

Town:

LGA:

Occupation:

Type of Employment:

Int'l Passport No.: (*)

Passport Valid Until: (*)

Passport Issuing Country: (*)

Destination Country: (*)

Purpose of Travel: (*)

Insurance Period From: (*)

To: (*)

Are you suffering from any sickness/disease/ailment under treatment? (*)

Next of Kin Name: (*)

Relationship: (*)

Contact Address: (*)

Applicant's Signature: (*)