1. Name
2. OFFICE/CONTACT ADDRESS
3. Town
4. City
5. State Of Origin
6. Country
7. Incorporation/Registration No
8. Date Incorporated/Registered
9. State of Incorporation/Registration
10. Country of Incorporation
11. Phone No
12. Email
13. Occupation
14. URL (if available):
15. Tax Identification No. (TIN)
16. Other existing Policies (if any)
17. Bank Verification No. (BVN)

18. Principal Officers	Designation	BVN

    Add More Officer Remove Officer
19. Nature of Business
20. How long have you been in Business
21. Are you insured at present

    please select Yes No
    If yes, give details of your present insurance
22. Nature of Cargo carried
23. What is your experience in the shipment of this kind of goods
24. Type of Packaging

    please select Bags Cartons Wooden Cases Bundles Shipment
25. Type of Cover

    please select Open Cover Single Transit
26. Mode of Transit

    please select Air Sea
27. Maximum Sum Insured Per Conveyance (Bottom Limit)
28. Expected Premium
29. Source of Funds
30. Bankers
31. Voyage/Transit: From
    To

32. Insurance Coverage Required

    1. Institute Cargo Clauses (A)
    2. Institute Cargo Clauses (B)
    3. Institute Cargo Clauses (C)
    4. Others, please specify
33. Has any Insurer declined or cancelled your business or imposed special terms

    please select Yes No
    If yes give details

Declaration

I / We agree that:

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

2. This Proposal shall form the basis of my / our contract with ENSURE INSURANCE Ltd.

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

4. No insurance will be in force until this

5. has been accepted by ENSURE INSURANCE Ltd and premium paid