An individual who assists an applicant to complete this proposal form for insurance shall be deemed to have done so as an agent

of the applicant

MOTOR

CONTACT ADDRESS

TELEPHONE NUMBER(S)

BUSINESS OR OCCUPATION RELIGION

NATIONALITY BANK NAME NUBAN ACCOUNT NUMBER BVN

ANNUAL INCOME BAND

UNDER N1.2 MILLION N1.2MILLION - N3MILLION N3 MILLION - N6 MILLION OVER N6MILLION

SOCIAL MEDIA ID

(Please continue on a separate sheet if necessary)

Please list and give the value of the non-standard accessories and extra fittings of the vehicle which are included in the estimated market value shown above

SUV

OTHERS (PLEASE SPECIFY):

IS THE CAR USED SOLELY FOR DOMESTIC AND PLEASURE PURPOSES (I.E NOT FOR HIRE OR REWARD) ?

9.

AMIPLC/CSD/MPF/08/2017/V1.1
 An individual who assists an applicant to complete this proposal form for insurance shall be deemed to have done so as an agent of the applicant

SECTION 4: DECLARATION
I/We hereby declare that the statements, answers given by Me/Us in this proposal form are true to the best of my/our knowledge and belief.

I/We hereby understand and agree that the statements, answers and particulars provided herein above are the basis on which this insurance is being
granted and that if, after the insurance is effected, it is found that any of the statements, answers or particulars are incorrect or untrue in any respect,
the company shall have no liability under this insurance.

I/We have read, understood and agree with the terms and conditions mentioned on this proposal form

(FOR COMPANIES ONLY)

AMIPLC/CSD/MPF/08/2017/V1.1