SHOP INSURANCE – Heirs Forms

SHOP INSURANCE PROPOSAL/KYC FORM

IMPORTANT

“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 PROPOSER

Name of Proposer:

Surname(*)

First Name(*)

Middle Name

Title(*)

Gender(*)

Date of Birth(*)

Email Address (*)

Phone Number (*)

Business or Profession (*)

When was the Company/Business Established?(*)

Tel No(*)

Office Address(*):

How Long have you occupied the premises? (*)

Total Value: (*) Kindly note that only transactions above 2 Million Naira is accepted and treated.

Are you the Only Occupier of the Premises? (*)
YesNo
Will the Premises be Occupied at all Times? (*)
YesNo

Give Details of any Property Contained in a Locked Safe: (*)

Does any of the Stock in Trade Consist of Valuation? (*)
YesNo
Do you Take Stock Regularly? (*)
YesNo
Are Stock Books Regularly Posted? (*)
YesNo

INSURANCE HISTORY

Is there any Insurance in Force on any of the Properties Insured? (*)
YesNo
Have you Ever Made a Claim from any Insurer for Theft or Burglary? (*)
YesNo
Has any Company Declined your Proposal for Burglary or Theft Risk? (*)
YesNo

DOCUMENT/INFORMATION TO BE SUBMITTED: * Please upload photocopies and bring along the original documents for confirmation.

How does your business operate?
IndividualCorporate

Type of Shop
OwnerTenant

Please provide the following:

1. Current Electricity/Other Utility Bill:

2. Valid ID (Driver’s License/National ID/International Passport):

3. Certificate of Incorporation/Registration:

4. Form CO2:

5. Form CO7:

6. Memorandum & Article of Association:

7. Authorization to Operate from Relevant Regulatory Bodies:

8. Shop Inventory:

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 (*):

Name of Referrer (*):

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