Application Form printable pdf download

Application Form

Personal Details

Are you Insured:

Yes

ID/Reg Number:

VAT Registration Number

Contact Person:

Date of Birth:

Address of Risk: (unless stated otherwise in schedules

Postal Address:

Email:

Telephone Number:

Fax Number:

Bank Details:

Bank:

Branch:

Branch Code:

Account Holder:

Account Number:

Premium Frequency: (annual, bi-annual, quarterly or monthly)

I hereby apply for the insurance indicated in this proposal as being required by my organization

and I agree (should the aforesaid insurance be granted) to accept such insurance in accordance

with the terms, exceptions, conditions and limitations of the policy issued by CORPORATE

GUARANTEE LTD. I declare that the terms under which this insurance is issued by

CORPORATE GUARANTEE LTD have been fully explained to me, in particular that the

aggregate of all claims under this insurance may never exceed the Policy Indemnity Limit as

defined by COPORATE GUARANTEE LTD. I further declare that I am duly authorised to make

this application on behalf of the proposer.

Signature

Date

Application Form