Proposal/Application Form

Driver’s Personal Assurance & Safety Scheme (Driver’s PASS)
Product
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Agent code
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Payment Mode*
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Amount Insured
₦
Amount Payable
₦
THE PROPOSER/APPLICANT
Surname*
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Other Names*
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Gender
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Date of birth *
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Address *
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Occupation*
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Phone Number*
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Alternate Phone Number
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Email Address*
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Means of Identity [Voter's card, National ID, Rider's Permit, Driver's license]*
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THE NEXT-OF-KIN DETAILS
Surname*
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Other names
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Relationship *
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Address *
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Gender
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Phone Number
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Email Address*
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By submitting this form you agree that the above details provided are true and complete and the insurance company issues a Policy in its usual terms and conditions.

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