I hereby declare that particulars given below are true and the APPOINTMENT for which I apply will be used only by myself for soliciting or procuring insurance business for your insurance company. I also declare that –
(1) I have not been found to be of unsound mind by a court of competent jurisdiction.
(2) I have not been found guilty of criminal misappropriation or criminal breach of trust or cheating or forgery or an abetment of or attempt to commit any such offence by a court of competent jurisdiction.
(3) I have not been found guilty of or to have knowingly participated in or connived at any fraud, act of mis-representation against an insurer or an insured.
(4) I agree to abide by the rules, regulations and guidelines laid down by NAICOM and your company from time to time.
OFFFICE USE
PERSONAL DETAILS
Full Name
Maiden Name
State of origin
Gender MaleFemale
Marital Status SingleMarriedDivorcedWidower
Date of Birth
Email Address:
Tel No:
Residential Address: Type here
Educational Qualification SSCEONDHNDBSCPGD
Insurance agency Part TimeFull Time
LICENSE & BANK ACCOUNT DETAILS
License No
Issue Date
Expiry Date
CIIN Reg No
ARIAN Reg No
Bank Account
Account No
BVN
Bank A/c Holder Name
Bank Name
GUARANTORS DETAILS
Guarantor 1 Surname
Guarantor 1 First Name
Guarantor 1 Middle Name
Relationship
Guarantor's Address: Type here
Guarantor's Address Proof (Submit any one address proof out of the list of acceptable documents) :
Guarantor's ID :
Guarantor 2
Guarantor 2 Surname
Guarantor 2 First Name
Guarantor 2 Middle Name
ADVISOR'S DOCUMENTS/ INFORMATION TO BE SUBMITTED:
1.Age Proof (Photo ID): Passport Copy, National Driving License, National Identity Card, Voters Registration :
2.Address Proof: Telephone bill/ Electricity bill/ Bank A/c Statement (Not more than THREE months old), Tenancy agreement, Letter (on letterhead) from clergy.
3. Education Proof : School/ College/ University degree certificate
4. Passport photograph (White Background):
Δ
