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Sunday February 5, 2012
Billboard Insurance Scheme Application & Schedule Form
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   Carrier Brochure (pdf)
   CPIP Brochure(pdf)
Personal Information
Title
First Name
Last Name
Nature of Business
Duration of Cover From To
   
Contact Information
Office Name
Office Address
 
 
City
State
Office Tel
E-mail
   
Section A & B: Property & Loss of Rent
  Type (glass, plastic, fiber, etc)
  OAAN Identification No
  Board Location  
  Street Name
  Town
  State
  Dimension

Width

 Length
  Construction Cost N
  Cost of Message N
  Annual Rent Receivable N
  Total Value N
   
Section C - Public Liability
  Limit of Indemnity any one accident or series any one event N 1,000,000.00
  Any one period of insurance Unlimited
     
  I/We hereby declare the truth o all the foregoing statement and that I/We have not withheld any material information which could influence the decision of the Company in regard to this insurance.

I/We agree that this Questionnaire shall form the basis of the insurance schedule to be expressed in the usual terms of the policy issued by the Company.
   
  Signature of Insured and/or his
Agents and /or Broker (your name pass as signature)
  Date
     
BY ORDER OF THE BOARD
THE LION OF AFRICA INSURANCE COMPANY LIMITED
   
 
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