Broker / Agent Portal A trusted partner committed to your insurance premium financing CarrotPay Premium Finance Broker / Agent Portal ✓ Application submitted successfully! We'll contact you soon. ✗ Error submitting form. Please try again. Application Type Customer Category Individual Family Club / Association Corporate / SME New or Renewal Policy NewRenewal Broker / Agent Information Business / Trading Name Broker / Agent Full Name Intermediary Type Insurance BrokerInsurance AgentCorporate Sales AgentOther Reg. Number (if applicable) Partner ID (optional) Phone Email Office Address State LGA Nationality ID TypeNINInternational PassportDriver's LicenceVoter's Card ID Number Authorisation & Accuracy Declaration SelectYes – I am authorised and information is accurate Required to submit on behalf of a customer. Customer Information – Individual Full Name (as per ID) Date of Birth Gender (optional)MaleFemale Phone Email Residential Address State LGA Nationality ID TypeNINInternational PassportDriver's LicenceVoter's Card ID Number Family Cover Number of Dependents Names of Covered Members Customer Information – Club / Association Club / Association Name Registration Number (CAC / Other) Contact Person (President / Secretary) Contact Phone Contact Email Club Address State LGA Number of Members Customer Information – Corporate / SME Company Name RC Number / Business Registration Industry / Sector Number of Employees Tax ID / TIN (optional) Primary Contact Person Contact Phone Contact Email Registered Office Address State LGA Authorised Signatory / Director Full Name Position / Title Date of Birth Phone Email Residential Address State Nationality ID TypeNINInternational PassportDriver's LicenceVoter's Card ID Number Insurance Policy Details Insurance Type MotorHealth (HMO)LifeTravelMarineFire / PropertyGroup / CorporateOther Insurance Provider / Underwriter Broker (if applicable) Policy Start Date Policy End Date Do you have a quotation? NoYes Quotation Reference Upload Quotation Premium & Financing Total Premium (₦) Down Payment (₦) Financing Amount (₦) Tenure3 Months6 Months9 Months12 Months Repayment FrequencyMonthlyQuarterly (where applicable) Bank Details & Debit Authorisation Bank Account Name Account Number Debit AuthorisationSelectYes – I authorise debits per repayment schedule Uploads Upload Valid ID Proof of Address CAC Docs / Constitution (if applicable) Board Resolution / Authorisation Letter (Corporate) Declarations & Consents Truth & Accuracy DeclarationSelectYes Consent to Credit Checks & VerificationSelectYes Accept Terms & Privacy PolicySelectYes Save Draft Submit Application Δ
