Welcome to Leadway Group : Commercial Insurance

Untitled Document

	Bancassurance Login
Username: Password:

Untitled Document

Home » Commercial Insurance » Quotes and Forms » Forms

SPDC - WEST PROPOSAL FOR MOTOR 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.

(a)

Proposer

Surname *

First Name *

Other Names

(b)

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

Tel. No. *

Residential Address

Tel. No.

(c)

Date of Birth

Day

Month

Year

(d)

Nationality
(if not Nigerian)

(e)

Marital Status

Married

Single

Particulars of all Vehicles to be insured

		Vehicle 1	Vehicle 2	Vehicle 3
a.	Make of each vehicle *
b.	Index mark & registration no. *
c.	Year of manufacture
d.	Date of purchase
e.	Proposer's estimate of present value (including accessories thereon)
f.	Proposer's estimate of present value (excluding accessories thereon)
g.	Chasis No. and Engine No. *

Do you wish to be covered under the following extensions:

(a)	Strike Riot and Civil Commotion
(b)	Third Party Property Damage extension
(c)	Flood

You wish to insure in respect of

(a)	Comprehensive Benefits
(b)	Third Party Liability only

Have there been any accidents or losses during the last THREE YEARS in connection with motor vehicles owned or used by you?

Yes

I agree with all the terms and conditions. click here to read terms and conditions.

Follow this link to go back the page you were previously looking at.

Untitled Document