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(*)

Gender(*)

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

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?(*):

If Yes, please Give Name of Insurer(*):

how long have you occupied the premise?(*):

No of years

No of months

Has any Insurance Company or Underwriter Ever?(*):

Refused to renew your Policy

Imposed any special Terms?

If the answer to any of the above is Yes, Please give details(*):

Have you suffered loss in the last three years?(*):

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

SOCIAL AND POLITICAL ACTIVITIES

What Social/Membership Club do you belong to?(*):

Do you or your spouse belong to any Political or Pressure Group?

Does any of your close relation belong to any political group

If Yes, Tick as Appropraite

PERSONAL ACCIDENT

RECREATION, PASTIMES AND INSURANCE COVER REQUIRED

Do you do any sport or Hazardous Pastime(*):

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 ? (*):

Travel Extensively or Reside temporarily outside Nigeria or visit countries in a state of war or civil unrest? (*):

Is this Insurance required outside the limits of Nigeria? (*):

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?

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.