Fidelity Guarantee 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

Value of Property/Cover/Insurance Annual Turnover Limit of Indemnity: Anyone Occurrence Anyone Period of Insurance Expected Premium Source of Funds Bankers How frequently are audits made Who are your external auditors Are all locations audited If no state why Date of last audit: Internal Bankers Date of last audit: External Bankers Are references from previous Employees required for all new Employees Are bank accounts reconciled by someone who is not authorized to deposit or withdraw from them What is the maximum value of money, negotiable instruments at one location.(during business hours, outside) What security measures are taken with respect to the transfer of money and/or negotiable instruments What security measures are taken with respect to the transfer of money and/or negotiable instruments State largest amount held by any employee at one time Goods How often are employees required to account for money received? Please state What steps are taken to ensure that all sums received by employees are accounted for? Please state Do employees pay in money or draw cash on employer’s bank account Do employees who handle money or goods have duties in connection with ledgers or stock record books? If yes give details State maximum amount of petty cash held Do employees pay in money or draw cash on employer’s bank account Are all disbursements other than petty cash made by crossed cheques Are all disbursements other than petty cash made by crossed cheques Is counter signature of all cheques required Are securities/goods subject to joint control by two or more employees What is the system for authorizing the purchase of goods and recording deliveries Is there system for authorizing the dispatch of goods and ensuring that dispatch is recorded and charged to the customer if yes,by whom are they signed and what amount is dual signature required Do any employees have full access to the cash and accounts or Stock/inventory controls? if yes, Please provide details Is there controlled access to all locations where money and/or stock are kept Is there controlled access to all locations where money and/or stock are kept Are all the premises containing money, stock etc. connected to a central intruder alarm system

Claim Information

Has there been any occasion to question the honesty or good conduct of any of the persons to be guaranteed

If so give details

List any act of dishonesty or incidents which have occurred during the last five years

Date	Description	Amount	Preventive Measures

Declaration

The information supplied in this proposal is true and complete and that I /We have not concealed, misrepresented or misstated any material fact.

This Proposal shall form the basis of my / our contract with ENSURE INSURANCE PLC

Immediate notice shall be given to ENSURE INSURANCE PLC of any alteration in the circumstances described herein.

No insurance will be in force until this Proposal has been accepted by ENSURE INSURANCE PLC and premium paid.

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)

I/We agree to accept a policy in the Company’s usual form for this class of insurance

Signature of Proposer

Date

OFFICIAL USE ONLY

Broker/Agent/BA

SBU/Hub/Spoke
Client’s Risk Category