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FIRE & SPECIAL PERILS, BURGLARY & HOUSE BREAKING,HOUSEHOLDER/CONSEQUENTIAL LOSS INSURANCE PROPOSAL/KYC FORM
An Insurance Agent who assists an applicant to complete an 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:
Date of Birth:
Trade or Business:
Type of Property Insured:
First Loss Sum Insured (if any):
What Type of Insurance?
Fire and Special Perils
Burglary and Housebreaking
Householder/Consequential Loss Insurance
Have you Ever been Insured for the Type of Cover Proposed?
If Yes, Please Give Name of Insurer:
How Long have you Occupied the Premises?
No. of Years:
No. of Months:
Has any Insurance Company or Underwriter Ever
Cancelled/Declined your Policy?
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?
Date of Loss (If Yes):
Nature of Loss:
Amount of Loss:
Name of the Insurance Company with which the Claim was Made:
Kindly use your favorite text editor (.docx, .xlsx, .pdf) and attach an inventory of items to be insured under 3 columns (Item No., Full Description of Property to be Insured, and Sum Insured)
CONSEQUENTIAL LOSS DETAILS:
(PLEASE COMPLETE IF YOU WISH TO EFFECT A CONSEQUENTIAL LOSS INSURANCE)
AMOUNT TO BE INSURED:
On Gross Premium: (The working expenses to be excluded are: Purchases (Less Discounts Received)).
Wages (if insured under): (For the first ..... weeks and .....% of the total wages roll for the remainder of the indemnity period).
On Auditors' Fees:
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 or Pressure Group?
If Yes to any of the questions above, Tick as Appropriate:
DOCUMENTS/INFORMATION TO BE SUBMITTED:
*Please provide photocopies and bring along the original documents for confirmation.
Type of Residence:
How Long has this been your Place of Residence?
No. of Years:
No. of Months:
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
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 filling the form.
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