Trade or Business
Year of Make:
Index Mark & Registration No:
Have you Ever been Insured for the Type of Cover Proposed?
If Yes, please Give Name of Insurer:
Has any Insurance company or Underwriter Ever
Cancelled your Policy?
Declined to Insure you?
Refused to Renew your Policy
Imposed any Specail Terms
Declined any Claims
If the Answer to any of the above is Yes, Give Details:
Have you in the Last Three Years Suffered a Loss:
If Yes, Give Date of Loss:
Amount of Loss:
Name of the Insurance Company with which the Claim was Made:
Date of Registration:
Nature of Business:
Names/Address of Company Directors:
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:
FOR INDIVIDUAL CLIENT:
State of Origin:
Local Government Area:
Type of Employment:
If Self Employed, Name of Employer:
Address of Employer:
Date of Employment:
Employer's Tel. No:
If Married, Name of Spouse:
Date of Birth of Spouse:
DOCUMENTS/ INFORMATION TO BE SUBMITTED:
1. Current Electricity/Other Utility Bill:
1. Valid ID (Driver’s License/National ID/International Passport):
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 above is Yes, please tick as appropriate?
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.
Name of Proposer: