07004347746
09122222200
wecare@heirsgeneralinsurance.com
TRAVEL INSURANCE PROPOSAL FORM
IMPORTANT INFORMATION
“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”.
DO NOT PAY CASH TO ANY AGENT. ONLY PAY INTO THE AUTHORISED COMPANY ACCOUNT.
FOR PERSONAL DETAILS
NAME OF THE ASSURED
Surname: (*)
First Name: (*)
Middle Name:
Mobile Number: (*)
Mobile Number 2:
Email Address: (*)
Contact Address: (*)
Office Address:
NIN: (*)
Gender: (*) MaleFemale
Date of Birth: (*)
Nationality: (*)
State: (*) AbiaAdamawaAkwa IbomAnambraBauchiBayelsaBenueBornoCross RiverDeltaEbonyiEdoEkitiEnuguFCTGombeImoJigawaKadunaKanoKatsinaKebbiKogiKwaraLagosNasarawaNigerOgunOndoOsunOyoPlateauRiversSokotoTarabaYobeZamfara
Town:
LGA:
Occupation:
Type of Employment: EmployedSelf Employed
Int'l Passport No.: (*)
Passport Valid Until: (*)
Passport Issuing Country: (*)
Destination Country: (*)
Purpose of Travel: (*)
Insurance Period From: (*)
To: (*)
Are you suffering from any sickness/disease/ailment under treatment? (*) YesNo
Next of Kin Name: (*) Relationship: (*) Contact Address: (*)
Applicant's Signature: (*)
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