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Accident Public Vehicles Business Private Vehicle Goods In Transit Fire

Accident Insurance

GROUP PERSONAL ACCIDENT INSURANCE PROPOSAL FORM
For insurance of financial aid to employees disabled by accident whether at or away from work

First Name

Last Name

Phone no.

Business/ Occupation

Preferred Method of Contact

Phone

other

Residential Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Insurance from

Insurance to

Are all persons to be insured in good state of health and free from physical defect or infirmity?

Please give particulars

Are you or have you ever been insured for these risks.

With which insurers and why was the insurance discontinued

Please indicate the number and brief particulars of accidents which have occurred during the past three years

By submitting this form, I/We hereby warrant and declare the truth of all the above statements and that I/We have not held any material information, and I/We hereby agree to give notice to Alliance & General
Insurance Company Ltd of any variation in My/Our profession, occupation or health of any of
the persons to be insured immediately such information shall come to my/our knowledge.
I/We further agree that this Declaration shall be the basis of the contract between me/us and
Alliance & General Insurance Company Limited and to accept a Policy subject to the terms
exceptions and conditions prescribed by the Company

Commercial Vehicle

First Name

Last Name

Phone no.

Business/ Occupation

Preferred Method of Contact

Phone

other

Residential Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Index mark & Reg. No.

Year, make, and model of the vehicle

Chassis & Engine No.

Number of seats

Goods carrying capacity

Estimates of value, including accessories

Type of Cover Required

Purpose of Vehicle

Other

Passenger Type

Period of Insurance commencing -

Are you the sole owner of the motor vehicle

Please indicate the owner or any other party who has an interest in the vehicle and the nature

To the best of your knowledge and belief, do you or does any person who will drive the vehicle suffer from physical infirmity or from defective vision

Have you or has any person who to your knowledge and belief driven the vehicle, during the past five years...

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State any pending prosecution (If any)

If you have been or is now insured in respect of any motor vehicle, please state the name of the insurers

Has any insurer ever...

Are you entitled to a 'No Claim' Discount under a previous insurance

Give particulars

Have you had accidents or losses in the past 3 years

Give particulars

DECLARATION
I/We, the above named, being desirous of effecting an insurance, as above described, do hereby
declare that the particulars of the proposal are true, that I/We have not omitted to disclose any
material fact, and I/We further agree that this Proposal and declaration shall be the basis of the
Contract between myself/ourselves and Alliance and General Insurance Company Limited. I/We
undertake that the vehicle or vehicles to be insured will be maintained in an efficient condition.
I/We further agree to accept a policy subject to the terms, provisions and conditions of the
Company

Building Liability

PROPOSAL FORM
BUILDERS LIABILITY (OPEN) INSURANCE
(under Sec. 64 of Ins. Act 2003)

First Name

Last Name

Phone no.

Preferred Method of Contact

Phone

other

Company Name (if applicable)

BusinessAddress

Address Line 1

Address Line 2

City

State

Zip Code

Country

Year of Incorporation

Area of Specialization

No. of Permanent Staff

Description of Projects to be Covered

Name and Address of other Professionals in Use

Name of MD/CEO

Qualifications

Date of Birth

Specialty(s)

Years in Continous Practice

Full Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

To which professional bodies in Nigeria do you belong? State membership status - Member, Fellow, Associate

Desired Coverage Start Date

Current Insurance Provider (if applicable)

Current Coverage Amount (if applicable)

Do you practice outside Nigeria?

Have you or any staff of the firms or other professional in use ever faced a disciplinary committee for: professional misconduct?

Give Details

Has a client, third party or employee ever filed a suit against you for any reason?

Give Details

Number of Qualified Builders/ Engineers in your firm

Details if Specialist Areas

Category of Contractor

DOES YOUR COMPANY CARRY OUT PREEMPLOYMENT CHECK OR OTHER INVESTIGATION

HOW MANY OF YOUR EMPLOYEES ARE CONTRACT STAFF

HOW MANY OF YOUR STAF ARE YOUR BLOOD RELATIONS

WHAT PERCENTAGE OF YOUR WORK NORMALLY INVOLVES PILING OR UNDERGROUND WORKS RAFT FOUNDATIONS OF BUILDINGS OR MORE THAN TWO (2) FLOORS?

Give Details

Does the business operate in multiple locations

Specify how many locations and provide details for each location

By submitting the form you declare that the above statement are true and correct and agree that this
proposal form shall the basis of the contract between us and the underwriter.

Motor Insurance

First Name

Last Name

Phone no.

Preferred Method of Contact

Phone

other

Date of Birth

Gender

Marital Status

Residential Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Driver's license number

Date of issuance

Country of issuance

Year, make, and model of the vehicle

Vehicle Identification Number (VIN)

Mileage on the vehicle

Vehicle usage

Primary Parking Location

Number of years of driving experience

Details of any previous accidents or claims (with dates and amounts paid)

Any traffic violations or tickets in the last few years

Current Insurance Provider (if applicable)

Current Coverage Amount (if applicable)

Information about other drivers who will be covered under the policy (if applicable), including their names, dates of birth, and driver's license information

Details of previous auto insurance policies, including the name of the previous insurer and the policy number.

Preferred payment method

Bank account or credit card information for premium payments

Any additional factors that may affect the policy, such as custom modifications to the vehicle or special equipment

Goods in Transit

GOODS IN TRANSIT INSURANCE PROPOSAL FORM FOR INSURANCE OF GOODS IN TRANSIT BY ROAD, RAIL OR INLAND WATER WAYS IN FEDERAL REPUBLIC OF NIGERIA

First Name

Last Name

Phone no.

Business/ Occupation

Preferred Method of Contact

Phone

other

Residential Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Insurance start date

Insurance end date

Do you want this insurance as....

If you have other insurance with the Company please specify

Give details of losses or damage in respect of goods in transit relating to you during the last three years, indicating amounts

State fully the nature and description of goods to be carried

State the area in which the vehicles operate in the ordinary course of business

Has any insurer ever

Will any of the following be carried?

What safety device do you have in your vehicles?

Estimated Total value of goods to be carried in any one year (NGN)

Maximum consignment anyone vehicle or conveyance

If this insurance is for a single consignment please indicate total value of goods being transported (in NGN) from the starting point to the destination

Specify the Starting Point

Specify the destination

By submitting this form I/We desire to effect an insurance in the terms of the usual Policy for Goods In Transit Insurance
and declare that the above statements and particulars are true. I/We further declare by submitting the form that this
proposal shall be the basis of the contract between me/us and Alliance & General Insurance
Company Ltd. I/We also are aware that our failure to insure for the full value of the property will
result in I/We receiving only a proportion of any amount that may be due in the vent of a loss or
damage

FIRE INSURANCE PROPOSAL FORM

First Name

Last Name

Phone no.

Preferred Method of Contact

Phone

other

Full address(s) of premises proposed for insurance

Address Line 1

Address Line 2

City

State

Zip Code

Country

Construction of Walls

Construction of Roofs

Construction of Floors

Number of storeys (note that a bungalow is regarded as one story building

Age and Condition of building(s)

Method of Lighting (and Heating, if any)

Is any retail trade carried on?

Give details

What manufacturing processes or repair work (if any) are carried on within the premises

What power is used? Electricity, gas or any other source

What other trade or business is carried on by the other occupants (if any) of the premises

Are there any hazardous goods located outside the building(s) and within 10 meters thereof. Please give details

Year of Incorporation

Is the whole building(s) used for business purpose or private dwelling (please give details)

Area of Specialization

No. of Permanent Staff

Name and Address of other Professionals in Use

Name of MD/CEO

Qualifications

Date of Birth

Specialty(s)

Years in Continous Practice

Full Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

To which professional bodies in Nigeria do you belong? State membership status - Member, Fellow, Associate

Desired Coverage Start Date

Current Insurance Provider (if applicable)

Current Coverage Amount (if applicable)

Do you practice outside Nigeria?

Have you or any staff of the firms or other professional in use ever faced a disciplinary committee for: professional misconduct?

Give Details

Has a client, third party or employee ever filed a suit against you for any reason?

Give Details

Number of Qualified Builders/ Engineers in your firm

Details if Specialist Areas

Category of Contractor

DOES YOUR COMPANY CARRY OUT PREEMPLOYMENT CHECK OR OTHER INVESTIGATION

HOW MANY OF YOUR EMPLOYEES ARE CONTRACT STAFF

HOW MANY OF YOUR STAF ARE YOUR BLOOD RELATIONS

WHAT PERCENTAGE OF YOUR WORK NORMALLY INVOLVES PILING OR UNDERGROUND WORKS RAFT FOUNDATIONS OF BUILDINGS OR MORE THAN TWO (2) FLOORS?

Give Details

Does the business operate in multiple locations

Specify how many locations and provide details for each location

By submitting the form you declare that the above statement are true and correct and agree that this
proposal form shall the basis of the contract between us and the underwriter.

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