“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):
Agent/Broker Name:
Agent/Broker Address:
Purpose of Use(*): CommercialPrivate
Chassis No(*):
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:
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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.
