Fire & Special Perils

What Type of Insurance?
Fire and Special Perils: Burglary and Housebreaking: Householder Insurance: Tenant Protect:

DETAILS OF PROPOSAL

Name of Proposer:

Surname:

First Name:

Middle Name:

Title:

Gender:

Date of Birth:

Trade or Business:

Tel. No.:

Email Address:

House Address:

BVN:

Commencement Date:

National ID No. (NIN):

Type of Property Insured:

Type of Residence: Owner Tenant

How Long has this been your Place of Residence?

Value of Property:

Sum Insured:

Were you referred? Yes No

If Yes, Please Give Name of Referrer:

Phone number of Referrer:

INSURANCE/LOSS HISTORY

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

If Yes, Please Give Name of Insurer:

How Long have you Occupied the Premises?

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

If the Answer to any of the Above is Yes, Please Give Details:

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

Date of Loss (If Yes)

Nature of Loss:

Amount of Loss:

Insurance Company where Claim was Filed:

SCHEDULE

Full Description of Properties and/or Content to be Insured	Sum Insured

POLITICAL ACTIVITIES

Is Customer a PEP? Yes No

If Yes, PEP Category?

DOCUMENTS/INFORMATION TO BE SUBMITTED:

1. Current Electricity/Other Utility Bill

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

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.