0700 434 7746

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MOTOR INSURANCE PROPOSAL/KYC FORM

IMPORTANT
An Insurance Agent who assists an applicant to complete an 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 (Mr/Mrs/Ms/Others): Gender: Male Female Date of Birth:

Day Month Year

Trade or Business: Tel No:

Email Address:

Business Address:

Commencement Date: Value of Vehicle:

Day Month Year

Name and Type of Vehicle: Colour:

Year of Make: Index Mark & Registration No:

Engine No: Chassis No:

INSURANCE/LOSS HISTORY

Have you Ever been Insured for the Type of Cover Proposed? Yes No

If Yes, Please Give Name of Insurer:

HAS ANY INSURANCE COMPANY OR UNDERWRITER EVER:

If the Answer to any of these is Yes, Give Details:
Cancelled your Policy? Yes No

Declined to Insure you? Yes No

Refused to Renew your Policy? Yes No

Imposed any Special Terms? Yes No

Declined any Claim? Yes No

Have you in the Last Three Years Suffered a Loss? Yes No

If Yes, Give Date of Loss: Amount of Loss:

Day Month Year

Name of the Insurance Company with which the Claim was Made:

COMPANY DETAILS

Date of Registration: Incorporation No:

Day Month Year

Nature of Business:

Names/Addresses of Company Directors:

HEIRS GENERAL INSURANCE LIMITED | Heirs Towers, Plot 107B, Ajose Adeogun Street, Victoria Island, Lagos - Nigeria | www.heirsgeneralinsurance.com

Authorized and regulated by the National Insurance Commission (NAICOM) 1 of 2

 DOCUMENTS TO BE SUBMITTED: * Please provide photocopies and also bring along original copies of the documents for conrmation.

1) Certicate of Incorporation/Registration 4) Form CO7

2) Memorandum & Article of Association 5) Copy of Authorization to Operate from Relevant Regulatory Bodies

3) Form CO2

FOR INDIVIDUAL CLIENT * Please provide photocopies and also bring along original copies of the documents for conrmation.

Nationality: State of Origin:

Local Government Area: Town:

Profession/Occupation: Designation:

Type of Employment: Employee Self Employed

If Self Employed, Name of Employer:

Address of Employer:

Date of Employment: Employer's Tel. No:

Day Month Year

Marital Status: Married Single Divorced Separated

If Married, Name of Spouse:

Wedding Anniversary: Date of Birth of Spouse:

Day Month Year Day Month Year

Beneciary:

DOCUMENTS/INFORMATION TO BE SUBMITTED: * Please provide photocopies and bring along the original documents for conrmation.

Current Electricity/Other Utility Bill Valid ID (Driver’s License/National ID/International Passport)

SOCIAL AND POLITICAL ACTIVITIES

What Social/Membership Club do you Belong to?

If Yes, Tick as Appropriate:

Do you or your Spouse Belong to any Political or Pressure Group? Yes No

Does any of your Close Relation Belong to any Political or Pressure Group? Yes No Parent Sibling Spouse In Law Other

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 ling the form.

Name of Proposer:

Signature:
Date:
Day Month Year

(Afx stamp here)

Agent/Company Representative:

HEIRS GENERAL INSURANCE LIMITED | Heirs Towers, Plot 107B, Ajose Adeogun Street, Victoria Island, Lagos - Nigeria | www.heirsgeneralinsurance.com

Authorized and regulated by the National Insurance Commission (NAICOM) 2 of 2