GENERAL ACCIDEINSURANCE 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(*)

Gender(*)

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?

Are you the only occupier of the premises?

Do you live on the premises?

Will the premises be occupied at all times?

Does any of the stock in trade consist of valuation?

Do you take stock regularly?

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?

Has there been any attempt by anyone to enter the premises occupied by you?

Have you Ever Made a Claim from any Insurer for Theft or Burglary?

Has any Company Declined your Proposal for Burglary or Theft Risk?

Cancelled or Refused to Renew your Policy?

Imposed any Special Terms?

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 Specied Vehicles(Please State Vehicle Model & Registration Number):(*)

Do you have any Vehicles other than those Mentioned In the Above Schedule?

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: