GENERAL ACCIDENT INSURANCE PROPOSAL/KYC FORM
“An Insurance Agents 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”.
Please answer ALL questions in full. Use CAPITAL LETTERS.
DETAILS OF PROPOSER Name of Proposer:
Surname(*)
First Name(*)
Middle Name
Title(*) MrMrsMsOthers
Gender(*) MaleFemale
Date of Birth(*)
Business or Profession: (*)
Tel No(*)
When was the Company Established?(*)
Email Address(*):
Business Address(*):
Nationality (*)
Insurance Commencement Date(*)
Insurance End Date(*)
Name and Phone Number of Contact Person (if Different from the above Proposer):
How long have you occupied the premises?
Are Stock Books Regularly Posted? —Please choose an option—YesNo
Are you the only occupier of the premises? —Please choose an option—YesNo
Do you live on the premises? —Please choose an option—YesNo
Will the premises be occupied at all times? —Please choose an option—YesNo
Does any of the stock in trade consist of valuation? —Please choose an option—YesNo
Do you take stock regularly? —Please choose an option—YesNo
Give details of any property contained in a Locked Safe:
Give Details of Anti-Theft Devices Installed on the Premises
INSURANCE HISTORY
Is there any Insurance in Force on any of the Properties Insured? —Please choose an option—YesNo
Has there been any attempt by anyone to enter the premises occupied by you? —Please choose an option—YesNo
Have you Ever Made a Claim from any Insurer for Theft or Burglary? —Please choose an option—YesNo
Has any Company Declined your Proposal for Burglary or Theft Risk? —Please choose an option—YesNo
Cancelled or Refused to Renew your Policy? —Please choose an option—YesNo
Imposed any Special Terms? —Please choose an option—YesNo
TYPE OF COVER REQUIRED(*) Please select the type of Insurance you wish to take): All-Risks InsuranceGoods-In-TransitBurglary & HousebreakingOthers Please Specify below
Goods in Transit Covers:
Please Provide Details of the Nature of the Goods to be Insured:(*)
If Cover is Required on Specied Vehicles(Please State Vehicle Model & Registration Number):(*)
Do you have any Vehicles other than those Mentioned In the Above Schedule? —Please choose an option—YesNo
If a Declaration Policy is Required, Please State:
The Estimated Aggregate Value of Goods which will be Carried During the Next 12 Months: (*)
The Maximum Value of any Given Consignment:(*)
If Cover is Required for a Single Transit Please Give Details of Journey:
From(*)
To(*)
If your Own Vehicles are Used, Please State:
Towns and Localities Where Vehicles will be Used:
If the Vehicles are not Fitted with Closed Bodies, what Precautions are Taken to Protect the Load?
Are any of the Vehicles Fitted with Immobilizer Alarms or Other Security Devices?YesNo
Does the Driver or an Attendant Remain with a Loaded Vehicle at all Times When it is not Within Securely Locked Building?YesNo
If not, what Steps are Taken to Protect the Load?
Have any of your Drivers Ever had Their Licenses Suspended or Endorsed? YesNo
Do the Vehicles Carry Fire Extinguishers? YesNo
If Yes, Please State Make:
Has a Proposal for Goods in Transit Insurance Ever been Submitted by you to any Insurer? YesNo
If Yes, Please State to Whom and with what Result?
Has Renewal Ever been Declined, or not Invited? YesNo
Has an Increased Rate Been Required? YesNo
Please State Complete Record of Loss or Damage to Goods in Transit During the Past 3 Years (Prepare & Upload with a file editor under the headings; SN, LOSS, DETAILS).
State Fully the Nature and Description of Goods Carried or Dispatched:
Estimated Annual Carrying:
Max. Value Per Carriage:
SOCIAL AND POLITICAL ACTIVITIES
What Social/Membership Club do you Belong to?
Do you or your Spouse Belong to any Political or Pressure Group? YesNo
Does any of your Close Relation Belong to any Political or Pressure Group? YesNo
If Yes, Tick as Appropriate: ParentSiblingSpouseIn LawOther
DOCUMENTS/INFORMATION TO BE SUBMITTED: * Please provide photocopies and bring along the original documents for confirmation.
Beneficiary
Type of Residence: OwnerTenant
How Long has this been your Place of Residence?
No. of Years
No. of Months
Please provide the following:
1) Current Electricity/Other Utility Bill
2) Valid ID (Driver's License/National ID/International Passport):
3) Certificate of Incorporation/Registration
4) Form CO2
5) Form CO7
6) Memorandum & Article of Association
7) Authorization to Operate from Regulatory Bodies
DECLARATION: I/We, hereby declare that the above particulars and answers are true and complete in every respect, and that no information has been suppressed or withheld. I/We further declare that if such statements and particulars are in the writing of any person other than myself/ourselves such person shall be deemed to have been my/our agent for the purpose of filing the form.
Name of Proposer:
Signature:
Date:
Agent/Company Representative
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