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Home » Commercial Insurance » Quotes and Forms » Forms
  PROPOSAL FOR "COMMERCIAL VEHICLE " 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.

1.
(a)  Proposer
Agent Individual
  TITLE  
  Surname * Surname is required.  
  First Name * First Name is required.  
  Other Names  
  NEE (if a married woman)  
         
(b) Full Postal Address *
(to which all correspondence would be sent)		 Postal address is required.  
  Tel. No. * Tel No is required.  
         
  Permanent Address  
  Tel. No.  
         
(c) Occupation
(Pls give full details)		  
  Fax. No.  
  E-mail Address * Email is required.Invalid format.  
         
(d) Date of Birth
Day   Month  Year
 
         
(e) Nationality
(if not Nigerian)		  
         
(f) Marital Status
Married Single Divorced Widow
 
         

PROPERTY TO BE INSUREDParticulars of all Vehicles to be insured
2.

 

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
a. Make of each vehicle *
b. Index mark & registration no. *
c. Type of body
d. CC
e. Maximum carrying capacity of vehicle
f. Year of manufacture
g. Date of purchase
h. Price paid by proposer
i. Proposer's estimate of present value (including accessories thereon) *
j. What Licence (i.e. A, B or C) do you hold?
A
B
C
A
B
C
A
B
C
A
B
C
k. State where vehicle (s) is/are usually garaged
           
           
l. Purpose of vehicle
m. If used for carriage of goods, state general nature
n. Has the vehicle been altered or adapted to carry a load heavier than that stated in the makers published specification?
o. State number of employees licensed to drive.
p. Are the vehicles at present in a thorough state of repair?
q. Are the brakes in good working order and regularly examined?
r. State town or locality in which vehicle will generally be used
3.
(a) Will you carry explosives and/or inflammable materials?
(b) Do you undertake cartage for other persons?
(c) Will any of the vehicles be let out on hire?
4. If used for carrying passengers
(a) Are the passengers carried for hire or reward?
(b) Are the vehicles used for public service?
5. To the best of your knowledge do you or does any other person who to your knowledge will drive, suffer from defective vision or hearing or from any physical infirmity?
6. Have you or has any other person who to your knowledge will drive, been convicted during the past five years of any offence in connection with any Motor Vehicle?
7. State total number of Motor Vehicles owned by Proposer.  
8. Are you now or have been insured in respect of any Motor Vehicle? If so, state name and address of Company or Underwriter.
9. Has any Company or Underwriter ever:
(a) Declined your proposal Yes No  
(b) Required you to carry the first portion of any loss? Yes No  
(c) Required an increased premium or imposed special conditions? Yes No  
(d) Refused to renew policy? Yes No  
(e) Cancelled your policy? Yes No  
10.


CLAIMS HISTORY
Please give a summary of any losses sustained in the last year

TOTAL COST OF SETTLED CLAIMS

Damage to Own Vehicle Third Party Others
Claim No.: Claim No.: Claim No.:
Amount: Amount: Amount:

Total number of Accidents and Losses

Year Number
Year Number
Year Number
Year Number

(No acknowledgement of any Premium or Deposit is valid unless upon the Company's Printed form)

CLAIMS NOT YET SETTLED

Damage to Own Vehicle Third Party Others
Claim No.: Claim No.: Claim No.:
Amount: Amount: Amount:

Total number of Accidents and Losses

Year Number
Year Number
Year Number
Year Number

 
11. Are you entitled to a "No Claim Discount" from your previous insurers in respect of any of the vehicles described in this proposal? Check box if yes  
12. You wish to insure in respect of
(a) Comprehensive Benefits
(b) Third Party Liability, Fire & Theft
(c) Third Party Liability only
12.
Are there any circumstances apart from those dealt with above which appear to increase the risk of loss or damage by any of the perils to be insured against? If so, give details.
13.
If there is any fire insurance in force on the same property, state:
(a) Name of Insurer(s)
(b) Amount of Insurance(s)
14.
Have you ever had a Proposal or Renewal of Insurance declined or a Policy cancelled or Renewal invited at an increased rate? If so, state name of Insurer and full particulars in each case
15.
Have you suffered loss by fire? If so, give particulars
(a) Year
(b) Policy No.
(c) Amount Claimed (Naira)
16.

Do you
(a) Take stock at least once a year?
(b) Keep a proper set of account books?
(c) Keep such books in a fire-proof safe? (If so, type of safe)
(d) Remove such books to another building when the above premises are closed?
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.
I agree with all the terms and conditions. click here to read terms and conditions.

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