Proposal/Application Form

Shop Insure
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
Surname*
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Other Names*
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Gender
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Phone Number*
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Occupation*
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Email Address*
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THE SHOP DETAILS
Address of shop*
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Type of Goods Sold
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How long has your shop been in the above address *
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Number of Staffs in the Shop *
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Type of materials used in construction of the Wall
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Type of materials used in construction of the Roof
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What is the average value of goods in stock in the shop
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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.