FIRE & SPECIAL PERILS, BURGLARY & PERSONAL ACCIDENT PROPOSAL/KYC 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”.
DETAILS OF PROPOSER Name of Proposer:
Surname(*)
First Name(*)
Middle Name
Title(*) MrMrsMsOthers
Gender(*) MaleFemale
Date of Birth(*)
Occupation/Trade/Business (*)
Tel No(*)
Email Address(*):
Business Address(*):
Nationality (*)
Commencement Date(*)
Type of Property Insured
Value
Sum Insured:
First Loss sum insured (if any)
Type of residence OwnerTenant
How long have you occupied the premises?(*):
No of years
No of months
INSURANCE/LOSS HISTORY
Have you ever been insured for the Type of Cover Proposed?(*): YesNo
If Yes, please Give Name of Insurer(*):
how long have you occupied the premise?(*):
Has any Insurance Company or Underwriter Ever?(*):
Refused to renew your Policy YesNo
Imposed any special Terms? YesNo
If the answer to any of the above is Yes, Please give details(*):
Have you suffered loss in the last three years?(*): YesNo
Nature of Loss(*):
CONSEQUENTIAL LOSS DETAILS: (PLEASE COMPLETE IF YOU TO EFFECT A CONSEQUENTIAL LOSS INSURANCE)
NB: If the above schedule is insufficient kindly upload an inventory of other items to be insured
AMOUNT TO BE INSURED:
On Gross Premium(*):
Wages (if insured under): (*):
Indemnity Period: (*):
Period 6 months12 months18 months
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 group YesNo
If Yes, Tick as Appropraite ParentSiblingSpousein-lawOther
PERSONAL ACCIDENT
RECREATION, PASTIMES AND INSURANCE COVER REQUIRED
Do you do any sport or Hazardous Pastime(*): YesNo
Pls Specify (*): NOTE: The following activities are not covered by the policy: football, hunting, mountaineering, polo, racing of any kind, winter sports, underwater breathing apparatus, use of woodworking machinery driven by mechanical power (except where it involves the insured’s occupation). If you require cover for any of the above activities, indicate the exact requirement.
Do you (Or intend to)(*): Undertake more than 20 Air Flights Annum or fly in other capacities than as a fare-paying passenger ? (*): YesNo Travel Extensively or Reside temporarily outside Nigeria or visit countries in a state of war or civil unrest? (*): YesNo Is this Insurance required outside the limits of Nigeria? (*): YesNo If Yes, state countries in which cover is required: (*):
Please, State the level of benefits you require (*):
Dealth Benefit
Medical Expenses
Permanent Disability
Temporary Disability
WHO IS CONSIDERED THE BENEFICIARY IN THE EVENT OF CLAIM? :
Insured/ Legal Representative in the Case of Death? InsuredApplicantLegal Representative
Beneficiary :
Relationship with the Insured :
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. Authorization to Operate from Relevant Regulatory Bodies:
5. Form CO2:
6. Form CO7:
7. Memorandum & Article of Association:
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 (*)
Disclaimer:
All premium payments are to be paid directly to Heirs Insurance Ltd UBA Account Number 1019317954. Please do not pay cash to any of our representatives as they are not authorised to receive cash.
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