PROPOSER’S PERSONAL DETAIL

1. Surname
2. Mother’s Maiden Name
3. First Name
4. Other Names
5. Title please select Mr Mrs Miss Other
6. Date of Birth
7. Office Address
8. Residential Address
9. Residential Town/City
10. Local Government Area
11. Country
12. Nationality
13. State of Origin
14. BVN
15. Preferred Correspondence Address please select Residential Office Nationality
16. Telephone No: Office
17. Mobile
18. Email
19. Marital Status please select Single Married Divorced Widowed
20. Gender please select Male Female
21. Employment Status please select Self_Employed Partnership Civil Servant Private Sector Employee
22. ANNUAL INCOME BAND (NGN):
    1. 1m-2m
    2. 2m-5m
    3. 5m-10m
    4. 10m-15m
23. Facebook ID
24. Linkedin ID
25. MEANS OF IDENTIFICATION please select NATIONAL ID DRIVER's LICENSE INT'L PASSPORT VOTERS CARD Others
26. ID Country Of Issue
27. ISSUING AUTHORITY
28. DATE OF ISSUE
29. DATE OF EXPIRY
30. RESIDENT PERMIT (FOR NON NIGERIANS):
31. PHYSICAL DESCRIPTION: HEIGHT WEIGHT (IN KG)

32. I Will Like To Receive My Policy Document Via

    1. Email(soft copy)
    2. Courier

RISK APPRAISAL CONSTRUCTION

1. House Type please select Detached Semi-Detached Terraced Bungalow Flat Guest House
2. Number of Bedrooms
3. Number of Storey's
4. On Which Floor Is Flat/Apartment Situated?
5. Year of Construction
6. What Is The Dwelling Built Of? please select Brick Stone Concrete Bungalow Flat Guest House
7. What Is The Dwelling Roofed With? please select States Tiles Concrete
8. Please state if any part of the dwelling is roofed with felt on timber?
9. Is the premises in good repair? please select Yes No

OCCUPANCY

1. Is the house fully owner-occupied? please select Yes No

   If no, please provide details
   
2. Is any part of the premises used for business or professional purposes? please select Yes No
3. Is any part of the premises let or sublet? please select Yes No

   If yes, how many tenants?
   
4. Do you provide accommodation for paying guest? please select Yes No

   If yes, how many?
   
5. Is the dwelling left unoccupied regularly during the day or night? please select Yes No
6. Is the dwelling left unoccupied for more than 30 consecutive days in any one period? please select Yes No
7. Is the premises particularly exposed to damage by storm, flood, subsidence or landslip? please select Yes No

   If the answer to any of the above is yes, please provide details

SECURITY

1. Are the doors fitted with key-operated security locks?

   please select Yes No
   
2. Are the doors fitted with key-operated security locks?

   please select Yes No
   
3. Are all accessible windows fitted with locks?

   please select Yes No
   

4. Is the dwelling fitted with the following:

   1. Fire Extinguisher

      please select Yes No
      
   2. Intruder Alarm

      please select Yes No
      
   3. Smoke Detector

      please select Yes No
      
   4. Thunder Arrestor

      please select Yes No
      

PROPERTY TO BE INSURED

1. Value of the building: NGN
2. Value of contents: NGN(please attached inventory sheet)
3. Valuable items
4. Cover to commence from TO

General Question

1. Have you been insured for the risk proposed in the past five years?

   please select Yes No
   If yes, please provide the name of the insurer
2. Have you had any insurances declined, cancelled or made subject to special conditions?

   please select Yes No
   
3. Have you made any claims, suffered any loss(es), whether insured or not in the past five years?

   please select Yes No
   If the answer is yes to any of the above questions, please provide details

4. If you have any of the following insurances with ALLIANZ NIGERIA INSURANCE Ltd, please state policy number:

   please input a tabled list of all insurances policy number with the following headers

   1. PRIVATE MOTOR

   2. COMMERCIAL VEHICLE

   3. LIFE EDUCATION

   4. OTHERS

Declaration

I, declare and warrant that the above information in this application, and in all documents submitted to ALLIANZ NIGERIA INSURANCE Ltd in connection with this application, whether in own handwriting or not, is true, correct and complete and will form the basis of the proposed contract. I agree that if any material information concerning the risk on the life/lives insured has not been fully disclosed, or if I have given any untrue, incorrect or incomplete answers, ALLIANZ NIGERIA INSURANCE Ltd reserves the right to cancel my cover and I shall forfeit all premiums paid.

I irrevocably authorize and request any Doctor or other person who may be in possession of, or hereafter acquire any information concerning my health to disclose such information to ALLIANZ NIGERIA INSURANCE Ltd.

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

RESTRICTIONS, WAR AND KINDRED RISKS

It is agreed and expressly understood that should the death of the life assured occur directly or indirectly from his/her engaging in or taking part in riot or strike, civil commotion, insurrection, war (whether war be declared or not) or any act incidental thereto, the total amount payable under this policy shall be limited to the total amount of the premiums actually paid under the policy (less all extra premiums and any amount already paid by the company under the policy) together with compound interest on the premiums so paid to the date of the death of the life assured, at the rate to be determined by the company provided always that the total amount so payable under the policy shall not be more than the value of the sum assured. The Assurer shall not recognise any claim arising from any medical impairment or condition of a Life Assured which occurred or which was diagnosed prior to commencement of the term of assurance under this Policy, or within six (6) months of such commencement.