Plant All Risk Proposal Form

Impotant Information

“AN INDIVIDUAL WHO ASSISTS AN APPLICANT TO COMPLETE THIS PROPOSAL FORM FOR INSURANCE SHALL BE DEEMED TO HAVE DONE SO AS THE AGENT OF THE APPLICANT”

PROPOSER’S PERSONAL DETAIL

Name
Contact Address
Town
State
City
Country
Phone No
Email
Occupation
Customer type(eg SME,individual,etc)
Incorporation/Registration No
Date Incorporated/Registered
State of Incorporation/Registration
Country of Incorporation
Tax Identification No. (TIN)
Bank Verification No. (BVN)
Risk Locations
Activities carried out in the premises
Cover period
Other existing policy (ies) (if applicable)
URL (if available)
FAX (if available):

SUBJECT MATTER OF INSURANCE

Types of Plant
Plant Name
Location of Use
Use of the Plant
Registration No
Builder/Model
Engine Make/Mode
H.P
Type
Date of Last Inspection/Survey
Are the plants subject to a mortgage or other financial agreement
If yes, please state:
1. Company
2. Loan Term
3. Approximate Loan Amount Outstanding

THE SUMS PROPOSED FOR INSURANCE (WHERE IT IS MORE THAN A PLANT)

Please input a tabled list of item that you want to insure and their value with the following header:
1. S/No
2. Items
3. Value
and the total value at the bottom
Do you presently have any insurance in respect of the proposed plant?(s)

If yes, what is the claim experience

Please input these following documents:

Complete KYC form
please provide Valid Means of Identification of 2 of the Board Members
1. Board of member1
  
  Means of Identification
2. Board of member2
  
  Means of Identification
Copy of Certificate of Incorporation
Copy of Memorandum/Article of Association (details of the current shareholding structure must be included)

Declaration

I/We declare to the best of my/our knowledge that the information given on this form is true to every respect. I/We declare that if anything on this form was written by another person, he or she acted as my/our agent for this purpose. I/We agree that this proposal and declaration shall be the basis of the contract between me/us and the insure

Name

Signature of Proposer