Bikers Insurance Proposal / KYC Form

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:

Cancelled/Declined your Policy? Yes No

Refused to Renew your Policy? Yes No

Imposed any Special Terms? Yes No

COMPANY DETAILS

Date of Registration:

Incorporation No.:

Nature of Business:

Names/Addresses of Company Directors:

DOCUMENTS/INFORMATION TO BE SUBMITTED:

1. Certificate of Incorporation/Registration:

2. Memorandum & Article of Association:

3. Form CO2:

4. Form CO7:

5. Authorization to Operate from Relevant Regulatory Bodies:

FOR INDIVIDUAL CLIENT

Nationality:

State of Origin:

LGA:

Town:

Type of Employment:
Employee Self Employed

If Self Employed, Name of Employer:

Address of Employer:

Date of Employment:

Employer's Tel. No.:

Marital Status:
Married Single Divorced Separated

If Married, Name of Spouse:

Wedding Anniversary:

Spouse Birth Date:

Beneficiary Name:

DOCUMENTS/INFORMATION TO BE SUBMITTED:

Current Electricity/Other Utility Bill:

Personal Identification:

Valid ID:

POLITICAL ACTIVITIES:

CONSENT

I (the Data Subject) hereby affirm that in line with the Nigeria Data Protection Regulation, 2019 (NDPR), I consent to the collection and processing of my personal data/information (within or outside Nigeria) in the absence of any fraud, duress, undue influence or coercion for the purpose of forming the basis of this insurance proposal/contract and other necessary data processing activities which may arise therefrom, including for the performance of the insurance contract between myself and HEIRS General Insurance Ltd. I affirm that I have the requisite capacity under the law to consent to the collection and processing of my personal data.

I further consent to the processing of my personal data, including transfer of my personal data to any third party for reasons associated with the purpose for which the data is being processed as stated above or processing for the marketing of HEIRS General Insurance Limited's existing or future products. I authorize and consent that medical practitioners who may be in possession of, or hereafter acquire any information pertaining to my medical records may disclose such information to HEIRS General Insurance.

I affirm that I am aware and take cognizance of my rights under the NDPR which include the right to request for access, amendment, rectification or cancellation or destruction of my personal data/information, the right to lodge complaint with the relevant authority as well as the right to object to the processing of my personal data.

DECLARATION

I declare that to the best of my knowledge that the information given in this proposal is true and complete and that I have withheld no material information regarding this proposal.

I agree that this declaration and the answers given above as well as any further proposal or declaration or statement made in writing by me or anyone acting on my behalf will form the basis of the contract between myself and Heirs General. I further agree to accept indemnity subject to the conditions and endorsed on the company's policy document.

I declare that the total sum insured represents not less than the full value of the property mentioned above and I agree that no insurance shall commence until this proposal has been accepted by Heirs General.