0700 434 7746
wecare@heirsgeneralinsurance.com
09122222200
“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(*) MrMrsMsOthers
Gender(*) MaleFemale
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(*): Third PartyComprehensive Private @5% (Excess buyback inclusive)Her Motor @5% (Excess buyback inclusive)Comprehensive Commercial @5%Flexi 25Flexi 35Flexi 70Bikers cover at 5%
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
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 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, 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 authorized to receive cash.
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