Proposal/Application Form

Shop Insure
Product
Agent code
Variant (Cover type)*
Amount Insured
Amount Payable
THE PROPOSER/APPLICANT
Title
Surname*
Other Names*
Gender Phone Number*
Occupation*
Email Address*
THE SHOP DETAILS
Address of shop*
Type of Goods Sold
How long has your shop been in the above address *
Number of Staffs in the Shop *
Type of materials used in construction of the Wall
Type of materials used in construction of the Roof
What is the average value of goods in stock in the shop