Proposal/Application Form

Marine Cargo Insurance
Product
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Agent code
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Payment Mode*
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Variant (Cover type)*
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Amount Insured
₦
Amount Payable
₦
THE PROPOSER/APPLICANT
Name of Insured*
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Customer type
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Date of Incorporation or Registration *
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Incorporation/Registration Number *
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Gender
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Date of birth *
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Contact Address *
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Occupation/Nature of Business *
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NIN (National Identification Number)*
Phone Number*
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Tax Identification No. (TIN)
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Bank Interest/Value
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Email Address*
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OTHER DETAILS
Entry Date [This is current Date of issuance]
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Commencement Date [Start date and End date is the date the insurance cover will commence. Both dates are only future dates.]
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Expiry Date [End date is not necessarily 365 days from start date]
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Cover Type
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Conveyance (Mode of Transit)
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Packaging Type (Mode of Transit)
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Proforma Invoice Number
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Upload Invoice*
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Description of Consignment (Subject matter/Interest)
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Voyage From
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Voyage To
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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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