“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”.
    Please answer ALL questions in full. Use CAPITAL LETTERS.

    Name of Proposer:

    YesNo Pls. Specify:
    NOTE: The following activities are not covered by the policy: football, hunting, mountaineering, polo, racing of any kind, winter sports, underwater breathing apparatus, use of woodworking machinery driven by mechanical power (except where it involves the insured’s occupation). If you require cover for any of the above activities, indicate the exact requirement.
    Undertake More Than 20 Air Flights Per Annum or Fly in Other Capacities Than as a Fare-Paying Passenger? YesNo
    Travel Extensively or Reside Temporarily Outside Nigeria or Visit Countries in a State of War or Civil Unrest? YesNo
    Is this Insurance Required Outside the Limits of Nigeria? YesNo
    If Yes, State Countries in which Cover is Required:
    Death Benefit: (Naira)
    Permanent Disability: (Naira)
    Medical Expenses: (Naira)
    Temporary Disability: (Naira)
    The Applicant/Principal/Association/Company? YesNo
    The Insured or in the Case of Death the Legal Representative? YesNo
    Type of Residence:
    How Long has this been your Place of Residence?
    No of Years
    No of Months
    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 Yes, Tick as Appropriate:
    ParentSiblingSpouseIn LawOther
    Current Electricity / Other Utility Bill
    Any of the Following Personal Identication Cards (please provide photocopy): Driver's LicenseNational IDInternational Passport
    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:
    Agent/Company Representative: