Credit Life Proposal Form

1 Impotant Information

AN INDIVIDUAL WHO ASSISTS AN APPLICANT TO COMPLETE AN APPLICATION OR PROPOSAL FORM FOR INSURANCE SHALL BE DEEMED TO HAVE DONE SO AS THE AGENT OF THE APPLICANT IN ACCORDANCE WITH SECTION 54(2), INSURANCE ACT, 2003

THE LIABILITY OF THE COMPANY DOES NOT COMMENCE UNTIL THIS APPLICATION IS ACCEPTED AND THE PREMIUM IS PAID IN ACCORDANCE WITH SECTION 50(1) OF INSURANCE ACT 2003

2 Details of Proposal Name of Company Address of the Company Town City State Country

Incorporation/Registration No

Date of Registration

State of Incorporation/Registration Country of Registration Operating Phone No(s) Email Address * Website FAX (if available) Tax Identification No. (TIN Bank Verification No. (BVN)

Principal Officers	Designation	BVN

Nature of Company’s business (state all) Estimated Total number of Loan Customers on a monthly basis

Does any other company or association now carry or has any other company or association ever carried any form of Group Credit Life Assurance on your Loan Customers

If Yes, submit detailed information on previous Group Credit Life Assurance Representative of the company with whom correspondence is to be made Amount of first premium(for official use) Effective date of cover

Declaration

The Company agrees to submit a schedule of all its customers Allianz Nigeria Insurance Plc not later than 30days after the inception of the loan. The Company also agrees to pay the required premiums to Allianz Nigeria Insurance Plc. However, please note that no insurance will be effective until This application has been approved and accepted by the company at its Head office

Signed at

Date

Please input these following documents:

Complete KYC form

Please provide Valid Means of Identification of 2(Two) of the Board Members

Board Member One(1)
Means of Identification

Board Member Two(2)
Means of Identification

Copy of Certificate of Incorporation

Copy of Memorandum/Article of Association (details of the current shareholding structure must be included)