FORTCORE
DEVICE INSURANCE FORM
“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.”
1. Select Device Type: (*) 5%
1. Device Name: (*)
2. Upload Device Image: (*)
3. Upload Image with Serial Number: (*)
4. Device Make: (*)
5. Device Model: (*)
6. Device Serial Number: (*)
7. Customer Name: (*)
8. Upload Customer ID: (*)
9. Customer Phone Number: (*)
10. Email Address (*)
11. Date of Birth: (*)
12. Device Value: (*) Number only eg. 1000000
13. Device Premium: (5% of Device Value)
14. Purchase Date: (*)
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