Motor Insurance Proposal / KYC Form

0700 434 7746

wecare@heirsgeneralinsurance.com

09122222200

MOTOR INSURANCE PROPOSAL / KYC FORM (INDIVIDUAL)

“An Insurance Agent who assists an applicant to complete 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”.

Details of Proposer

Surname *

First Name *

Middle Name

Title *

Gender *

Date of Birth *

Email Address *

Telephone *

Residential Address *

Nationality *

State of Origin *

LGA

Town

Occupation *

Wedding Anniversary

Agent/Broker Name

Agent/Broker Address

Plan Type

Details of Vehicle

Vehicle Make *

Vehicle Model *

Vehicle Value *

Purpose of Use *

Vehicle Reg. No. *

Chassis No. *

Engine No.

Year of Make *

Colour *

Click here to fill vehicle fleet sheet, if applicable.

Documents/Information to be submitted

Proof of Ownership

Vehicle License

Means of ID

Vehicle Pictures (Upload a file with the multiple pictures.)

Evidence of Payment

Upload Excel Sheet of Vehicle Fleet

Insurance/Loss History

Do you have an existing policy on this type of cover *

If Yes, please give name of Insurance Company

Have you in the last 3 years suffered a loss or refused a claim *

If Yes, give details of loss

Loss Amount

Name of Insurance Company with which the claim was made

Do you or your spouse or members of your organization belong to any political or pressure group? *

If Yes, please give details

Declaration

I/We hereby declare that the above particulars are true and complete and no information has been withheld.

I concur that the details provided are true and permit inclusion in Heirs Insurance mailing list.

Comment (if any)

Disclaimer:
All premium payments must be paid directly to Heirs Insurance Ltd UBA Account No. 1019317954. Please do not pay cash to representatives.