BANCASSURANCE PROFILE APPLICATION FORM

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

Branch Name

Regional Sales Coordinator Name

Position Name

Reporting Manager (L1) Name

PERSONAL DETAILS

Full Name

Maiden Name

State of origin

Gender

Marital Status

Date of Birth

Email Address:

Tel No:

Residential Address:
Type here

Residential Address Proof (Submit any one address proof out of the list of acceptable documents) :

Office Address
Type here

Educational Qualification

Insurance agency

LICENSE & BANK ACCOUNT DETAILS

BRO Certification by college of insurance

Bank Account

Account No

BVN

Bank A/c Holder Name

Bank Name

NEXT OF KIN

Surname

First Name

Middle Name

Maiden Name

Relationship

Email Address:

Tel No:

Nominee Address:
Type here

GUARANTORS DETAILS

Guarantor 1 Name

Maiden Name

Relationship

Email Address:

Tel No:

Guarantor's Address:
Type here

Guarantor's Address Proof (Submit any one address proof out of the list of acceptable documents) :

Guarantor's Address ID :

Guarantor 2

Guarantor 2 Name

Maiden Name

Relationship

Email Address:

Tel No:

Guarantor's Address:
Type here

Guarantor's Address Proof (Submit any one address proof out of the list of acceptable documents) :

Guarantor's ID :

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: