Name of Dealer
Name of Station
Email Address
Phone No.
Fax No.
Location of Station
Kindly Select your prepared Plan
 
Message
  Sum Insured Annual Premium
Plan A 500,000.000 7,836.51
Plan B 750,000.00 8,507.86
Plan C 1,000,000.00 9,179.21
Plan D 2,000,000.00 11,864.52
Plan E 5,000,000.00 19,920.85
Plan F 11,000,000.00 36,033.29
Note : Annual Premiums are inclusive of taxes and may vary depending on the specific requirements of the dealer/assured.

I hereby apply for insurance cover as set out in the Insurance Company's Gasoline Dealers Insurance Program and I hereby warrant the above particulars are true and correct and I agree that this proposal be the basis of the policy contract between myself and the Insurance Company.

 
 
   
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