Personal Accident Form – HGI

PERSONAL ACCIDENT INSURANCE PROPOSAL/KYC

“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.

DETAILS OF PROPOSERName of Proposer:

Title: (*)

Surname: (*)

First Name: (*)

Middle Name: (*)

Gender: (*)

Date of Birth: (*)

Occupation/Profession: (*)

Tel Number (1): (*)

Tel Number (2):

Email Address: (*)

Address of Proposer: (*)

Nationality: (*)

Marital Status: (*)

Employment Status: (*)

Nature of Job: (*)

Period of Insurance: (*)

From:

To:

RECREATION, PASTIMES AND INSURANCE COVER REQUIRED

Do you do any Sport or Hazardous Pastime? (*)

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.

DO YOU (OR INTEND TO):

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:

PLEASE, STATE THE LEVEL OF BENEFITS YOU REQUIRE:

Death Benefit: (Naira)

Permanent Disability: (Naira)

Medical Expenses: (Naira)

Temporary Disability: (Naira)

WHO IS CONSIDERED THE BENEFICIARY IN THE EVENT OF CLAIM?

The Applicant/Principal/Association/Company? YesNo

The Insured or in the Case of Death the Legal Representative? YesNo

Beneficiary:

Type of Residence:

OwnerTenant

How Long has this been your Place of Residence?

No of Years

No of Months

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

ADDITIONAL DOCUMENTS/INFORMATION TO BE SUBMITTED:

Current Electricity / Other Utility Bill

Any of the Following Personal Identication Cards (please provide photocopy): Driver's LicenseNational IDInternational Passport

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: