“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”.
Risk Address (if different from business address)
Name of Company Directors:
Addresses of Company directors (as listed above):
Purpose of Use(*):
1. Certificate of Incorporation:
2. Memorandum & Article of Association:
3. Form CO2:
4. Form CO7:
5. Copy of Authorization to Operate from Relevant Regulatory Bodies:
6. Credit Note/Payment (Brokers only):
7. Upload Excel Sheet of Vehicle Fleet:
8. Vehicle(s) Picture:
Do you have an existing policy on this type of cover(*)
If Yes, please give name of insurance company(*):
Have you in the last 3 years suffered a loss or refused a claim(*)?
If Yes, give details of loss:
Name of the Insurance Company with which the Claim was Made:
Do you or your spouse or members of your organization belong to any political or pressure group?(*)
If Yes, give details:
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.