Trade or Business
Email Address:
Tel No:
Business Address:
Year of Make:
Index Mark & Registration No:
Engine No:
Chasis No: INSURANCE/LOSS HISTORY
Have you Ever been Insured for the Type of Cover Proposed? YesNo
If Yes, please Give Name of Insurer: Has any Insurance company or Underwriter Ever
Cancelled your Policy? YesNo
Declined to Insure you? YesNo
Refused to Renew your Policy YesNo
Imposed any Specail Terms YesNo
Declined any Claims YesNo
If the Answer to any of the above is Yes, Give Details:
Have you in the Last Three Years Suffered a Loss: YesNo
If Yes, Give Date of Loss:
Amount of Loss:
Name of the Insurance Company with which the Claim was Made:
COMPANY DETAILS:
Date of Registration:
Incorporation No:
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:
Nationality:
State of Origin:
Local Government Area:
Town:
Profession/Occupation:
Designation:
Type of Employment: YesNo
If Self Employed, Name of Employer:
Address of Employer:
Date of Employment:
Employer's Tel. No:
Marital Status: MarriedSingleDivorcedSeparated
If Married, Name of Spouse:
Wedding Anniversary:
Date of Birth of Spouse:
Beneficiary: :
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? YesNo
Does any of your Close Relation Belong to any Political or Pressure Group? YesNo
If above is Yes, please tick as appropriate? ParentSiblingSpouseIn LawOther
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.
Name of Proposer:
Signature
Date:
Agent/Company Representative::
