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PROPOSAL FOR "ALL RISKS" INSURANCE

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

(a)

Proposer

Agent

Individual

TITLE

Surname *

First Name *

Other Names

Maiden Name

(b)

Full Postal Address *
(to which all correspondence would be sent)

Tel. No. *

Permanent Address

Tel. No.

(c)

Occupation
(Pls give full details)

Fax. No.

E-mail Address *

(d)

Date of Birth

Day

Month

Year

(e)

Nationality

(f)

Marital Status

Married

Single

Divorced

Widow

(a)	Is the residence containing the property to be insured a private dwelling house, flat apartment or duplex?
(b)	If a flat, apartment or duplex, is it self-contained.

If any part of the premises is occupied for other than residence please state for what purpose.

Will the residence regularly be left without an occupant during the day time?

Is the residence occupied solely by yourself and family?

Please describe the construction of the external doors of your apartment and how they are locked if they are sliding or glass parallel doors, are they protected by iron or metal bars?

Are all the external windows protected by iron bars or welded mesh?

Is the night watchman in attendance at night?

Do the sums to be insured represent the full value of the property?

10.

(a)	Have you previously proposed for insurance against fire, Burglary or "All Risks"
(b)	Has any Insurer declined or required special terms to insure you or cancelled or refused to renew your insurance against such risks?
(c)	During the past five years, have you made a claim under an insurance against such risks or sustained any loss or damage which would be covered by such insurance?

11.

State whether the Geographical Limits are:
Anywhere in Nigeria
Anywhere in Africa
Limited to the Insured Premises

Please note that details of all items to be insured and their respective sums should be sent by fax or mail to our Corporate Office for further processing. Details should include (i) Description of items (ii) Location (iii) Sum Insured.

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F36R4

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