Liability Insurance Proposal / KYC Form

Are All the Premises in Good State of Repair? Yes No

Do you Have Vehicles or Cycles Which are not Power Driven? Yes No

Do you Have Good Lifts, Cranes or Hoists? Yes No

Are Such Lifts, Cranes or Hoists Regularly Inspected to Meet Statutory Requirements? Yes No

By Whom are the Lifts, Cranes or Hoists Inspected?

Give Details of any Mobile Plant and/or Vehicle Not Licensed for Road Use:

State What Acids, Gases, Chemicals, Explosives or Radioactive Materials that May be Used and to What Extent:

Type of Cover Required:	Limit Per Loss:	Limit Per Period:
Public Liability Insurance
Product Liability Insurance
Professional Indemnity
General 3rd Party Liability Insurance

INSURANCE/LOSS HISTORY

POLITICAL ACTIVITIES:

COMPANY DETAILS

Date of Registration:

Incorporation No.:

Nature of Business:

Names of Bankers:

Address of Bankers:

Names of Auditor:

Address of Auditor:

Names/Addresses of Company Directors:

Name of Direcotor:

Address of Director:

Name of Director:

Address of Director:

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:

6. Schedule of Employees (with their estimated annual earnings):

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:

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.