FIRE & SPECIAL PERILS, BURGLARY & HOUSE BREAKING,HOUSEHOLDER/CONSEQUENTIAL LOSS INSURANCE PROPOSAL/KYC FORM

IMPORTANT

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:

Surname:

First Name:

Middle Name:

Title: Mr.Mrs.Ms.Others

Gender: MaleFemale

Date of Birth:

Trade or Business:

Tel. No.:

Email Address:

Business Address:

House Address:

Commencement Date:

Type of Property Insured:

Value:

Sum Insured:

First Loss Sum Insured (if any):

What Type of Insurance?

Fire and Special Perils

Burglary and Housebreaking

Householder/Consequential Loss Insurance

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 Premises?

No. of Years:

No. of Months:

Has any Insurance Company or Underwriter Ever

Cancelled/Declined your Policy?
YesNo

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

Date of Loss (If Yes):

Nature of Loss:

Amount of Loss:

Name of the Insurance Company with which the Claim was Made:

SCHEDULE: 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:

Indemnity Period:

From:

To:

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 or Pressure Group?
YesNo

If Yes to any of the questions above, Tick as Appropriate:
ParentSiblingSpouseIn LawOther

DOCUMENTS/INFORMATION TO BE SUBMITTED: *Please provide photocopies and bring along the original documents for confirmation.

Beneficiary:

Type of Residence:

OwnerTenant

How Long has this been your Place of Residence?

No. of Years:

No. of Months:

Please provide the following:

1) Current Electricity/Other Utility Bill2) Valid ID (Driver's License/National ID/International Passport)3) Certificate of Incorporation/Registration4) Authorization to Operate from Relevant Regulatory Bodies5) Form CO26) Form CO77) 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 filling the form.