Motor Insurance Form – Heirs Forms

“An Insurance Agent 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”.

DETAILS OF PROPOSER
Name of Proposer:

Surname(*)

First Name(*)

Middle Name

Title(*)

Gender(*)

Date of Birth(*)

Email Address(*):

Tel No(*):

Residential Address(*):

Nationality (*)

State of Origin(*)

Local Government Area

Town

Occupation (*)

Wedding Anniversary (if married)

Agent/Broker Name:

Agent/Broker Address:

PLAN TYPE

Please select the preferred plan type(*):

DETAILS OF VEHICLE

Make of Vehicle:(*)

Value of Vehicle:(*)

Purpose of Use(*):

Colour:

Year of Make:

Vehicle Reg No(*):

Engine No:

Chassis No(*):

Click here to fill vehicle fleet sheet

DOCUMENTS/ INFORMATION TO BE SUBMITTED:

1. Proof of Ownership:

2. Vehicle License:

3. Means of ID:

4. Pictures of Vehicle:

5. Evidence of Payment:

6. Upload Excel Sheet of Vehicle Fleet:

INSURANCE/LOSS HISTORY

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:

Loss Amount:

Name of 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, please 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 concur that the details provided are true and permit that my details be added to the mailing list of Heirs Insurance.

Comment (if any):

Disclaimer:

All premium payments are to be paid directly to Heirs Insurance Ltd UBA Account Number 1019317954. Please do not pay cash to any of our representatives as they are not authorised to receive cash.