PERSONAL ACCIDENT PROPOSAL / KYC FORM

Marital Status:
Married Single Divorced

Type of Employment:
Self Employed Employee Unemployed

Nature of Job:

Period of Insurance: From To:

RECREATION, PASTIMES AND INSURANCE COVER REQUIRED

Do you do any Sport or Hazardous Pastime? Yes No

Pls Specify:

NOTE: The following activities are not covered by the policy: football, hunting, mountaineering, polo, racing of any kind, winter sports, underwater breathing apparatus, use of woodworking machinery driven by mechanical power (except where it involves the insured's occupation). If you require cover for any of the above activities, indicate the exact requirements.

DO YOU (OR INTEND TO):

Undertake More Than 20 Air Flights Per Annum of Fly in Other Capacities Than as a Fare-Paying Passenger? Yes No

Travel Extensively or Reside Temporarily Outside Nigeria or Visit Countries in a State of War or Civil Unrest? Yes No

Is this insurance Required Outside the Limits of Nigeria? Yes No

If Yes, State Countries in which Cover is Required:

PLEASE, STATE THE LEVEL OF BENEFITS YOU REQUIRE:

Death Benefits: (N)

Permanent Disability: (N)

Medical Expenses: (N)

Temporary Disability: (N)

WHO IS CONSIDERED THE BENEFICIARY IN THE EVENT OF CLAIM?

The Applicant/Principal/Association/Company? Yes No

The Insured or in the Case of Death the Legal Representative? Yes No

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:

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.