MOTORCYCLE/TRICYCLE CLAIM FORM

Instruction: Use ( ) or underline where appropriate.

NOTE: The Company does not admit liability by the issue of this form. i. The information provided is to enable the Company’s Solicitors to advise on and to conduct any legal proceedings which may ensue ii. Kindly provide picture evidence of the damaged property or bodily injury/death as a result of an accident.

Corporate Information

Company name

Address

Business Type

Incorporation/RC Number:

Incorporation StartDate

Website

Tax No:

Company No:

Regulatory

Please provide the Regulatory License Number

Do you have an Anti-Money Laundering and Bribery and Corruption Program?

Company Details

Please list details of the Company’s Executive and Senior Management

Fullname

Nationality

Country of residence

Position/Function

Please list details of the Company’s Direct Shareholders (any Shareholder holding 10% or more of the Company’s shares as currently known):

Fullname

Nationality

Country of residence

Position/Function

Director’s Information

Title

Surename

Othername

Gender

D.O.B

Nationality:

Occupation:

Tax No:

Phone No:

Address

Director’s Identity Document

Type of ID:

ID NO:

Issue Date:

Expiry Date:

Issue Authority:

Issue Country:

Address:

Supporting documents

Regulatory License issued by the Company’s Regulator

Copies of Current Constitutional Documentation

Certificate of Incorporation

Documentation listing registered directors (Form CAC 7 or equivalent)

Documentation listing registered shareholders (Form CAC 2 or equivalent)

Memorandum and Articles of Association

Authorized Person’s valid form of identification (Y/N)

DECLARATION

We hereby confirm to the best of our knowledge and belief that the information contained in this questionnaire and any attachment hereto is correct, and we have taken all reasonable to enable that this is the case.
We hereby confirm to the best of our knowledge, that our Entity is not dealing with any sanctioned person and we have taken all reasonable steps to ensure that this is the case.
We hereby confirm that the below signatory is authorized to act on behalf of the company

Name:

Position/Company:

date:

Signature & Company Stp:

MOTORCYCLE/TRICYCLE CLAIM FORM

Corporate Information

Regulatory

Company Details

Director’s Information

Director’s Identity Document

Supporting documents

DECLARATION

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