“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”.
COMPANY DETAILS
Company Name(*):
Company Email(*):
Company Tel No(*):
RC No(*)
Nature of Business(*)
Business Address(*)
Risk Address (if different from business address)
Name of Company Directors:
Addresses of Company directors (as listed above):
Agent/Broker Name:
Agent/Broker Address:
DETAILS OF VEHICLE
Make of Vehicle(*)
Value of Vehicle(*):
Purpose of Use(*): CommercialPrivate
Colour:
Year of Make:
Vehicle Reg No(*):
Engine No:
Chassis No(*):
Click here to fill vehicle fleet sheet
DOCUMENTS TO BE SUBMITTED:
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: [multilinefile vehicle-fleet]
INSURANCE/LOSS HISTORY
Do you have an existing policy on this type of cover(*) YesNo
If Yes, please give name of insurance company(*):
Have you in the last 3 years suffered a loss or refused a claim(*)? YesNo
If Yes, give details of loss:
Loss Amount:
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?(*) YesNo
If Yes, give details:
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.
I concur that the details provided are true and permit that my details be added to the mailing list of Heirs Insurance.
[checkbox* consent I concur that the details provided are true and permit that my details be added to the mailing list of Heirs Insurance.(*)]
Name of Agent/Company Representative:(*)
Disclaimer
All premium payments are to be paid directly to Heirs Insurance Ltd UBA Account Number 1023719467 or raise cheque in the name of Heirs Insurance. Please do not pay cash to any of our representatives as they are not authorised to receive cash.
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