GENERAL ACCIDENT PROPOSAL / KYC FORM

Proposer Type?
Individual: Corporate:

DETAILS OF PROPOSER

Title:

Surname:

First Name:

Middle Name:

Gender:

Date of Birth:

Business or Profession:

Company Establishment Date?

Telephone:

Office Address:

Email Address:

Period of Insurance; From:

To:

Name and Phone Number of Contact Person (if Different from the above Proposer):

Name:

Phone Number:

How Long Have you Occupied the Premises?

Are you the Only Occupier of the Premises? Yes No

Do you Live on the Premises? Yes No

Will the Premises be Occupied at all Times? Yes No

Does any of the Stock in Trade Consist of Valuation? Yes No

Do you Take Stock Regularly? Yes No

Are Stock Books Regularly Posted? Yes No

Give Details of any Property Contained in a Locked Safe:

Give Details of Anti-Theft Devices Installed on the Premises:

INSURANCE HISTORY

Is there any Insurance in Force on any of the Properties insured? Yes No

Has any Attempt Even been Made to Enter the Premises Occupied by you? Yes No

Have you Ever Made a Claim from any insurer for Theft or Burglary? Yes No

Has any Company Declined your Proposal for Burglary or Theft Risk? Yes No

Cancelled or Refused to Renew your Policy? Yes No

Imposed any Special Terms? Yes No

Type of Cover Required (Please select the type of Insurance you wish to take):
All-Risks Insurance Burglary & Housebreaking Goods-In-Transit Others

If Others, Please Specify below:

Goods In Transit Covers:

Please Provide Details of the Nature of the Goods to be insured:

If Cover is Required on Specified Vehicles (Please State Vehicle Model & Registration Number):

Do you have any Vehicles other than those Mentioned in the Above Schedule? Yes No

If a Declaration Policy is Required, Please State:

The Estimated Aggregate Value of Goods which will be Carried During the Next 12 Months:

The Maximum Value of any Given Consignment:

If Cover is Required for a Single Transit Please Give Details of Journey; From:

To:

If your Own Vehicles are Used, Please State:

Please State Complete Record of Loss or Damage to Goods in Transit During the Past 3 Years;

Loss:	Details:

State Fully the Nature and Description of Goods Carried or Dispatched:

Estimated Annual Carrying:

Max. Value Per Carriage:

POLITICAL ACTIVITIES:

Is Customer a PEP? Yes No

If Yes, PEP Category?

ADDITIONAL DOCUMENTS/INFORMATION TO BE SUBMITTED:

Current Electricity/Other Utility Bill:

Personal Identification:

Valid ID:

DECLARATION

Signature

Date