E- Business Portal

Enter National Identification Number or Bank Verification Number

Use BVN

National Identification Number *

Customer Information

First Name *

Middle Name

Surname *

Gender *

Mobile Number *

Email *

Occupation *

Residential Address *

Nationality *

State *

City / Town *

LGA *

Date of Birth *

Means of ID *

Means of ID No *

Upload Means of ID *

Date of Issue *

Exipry Date *

Resident Permit (applicable to foreigners resident in Nigeria)

Type of Employment *

Risk Details

Vehicle Class *

Cover Type *

Chasis Number *

Vehicle Reg No

Vehicle Type *

Vehicle Make *

Vehicle Model *

Vehicle Year *

Vehicle Color *

Engine No *

Engine Capacity *

Seat capacity *

Mileage *

Estimated Present Value (Including Accessories) *

Vehicle Purpose *

Location (Address) Where The Vehicle Can be Inspected

Do You Have a Driver's License or Learner's Permit?

How Long Have You Been Driving Motor Vehicle Continuously? *

Have There Been Accidents or Losses During The Last Three Years in Connection With Motor Vehicles Owned or Used by You? *

If Yes Give Reason (optional)

Declaration: I/We do hereby declare that the above statements and particulars are true, and I/We that this proposal and declaration shall be the basis of a contract of insurance between me/us and I am/We are willing to accept a policy subject to the terms, exceptions and conditions prescribed by the company therein. I/We confirm that I am authorized to fill this data collection form and authorize REX Insurance Limited Limited to collect and use the information disclosed thereon in accordance with the relevant Laws & Regulations of the Federal Republic of Nigeria. I hereby certify to the best of my information and belief, that the above information that I have supplied is true and correct in all material respects.

I agree to the Terms and Conditions and Declaration

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