EMPLOYERS LIABILITY WORKMEN COMPENSATION GROUP PERSONAL ACCIDENT INSURANCE PROPOSAL FORM/KYC FORM

IMPORTANT

An Insurance Agent who assists an applicant to complete an application or proposal form for insurance shall be deemed to have done so as the agent of the applicant – Section 54 (2) Insurance Act 2003.Please answer ALL questions in full. Use CAPITAL LETTERS.

DETAILS OF PROPOSER

Name of Proposer:

Address of Proposer (Not P.O. Box):

Trade or Business:

Telephone Number:

Email Address:

Period of Insurance:

From:

To:

Description of Activities/Business or Occupation:

No. of Employees/Workers/Members in the following Categories

Expatriates:

Mgt/Admin/Clerical (Non-manual Labour):

Supervisory Roles (Non-clerical Staff):

Others (Occupations to be described):

OTHER DETAILS

Are you Engaged in any Hazardous Pastimes or Sport? If so, please state:
Yes
No

Do you Foresee being Engaged in Air Transit Other Than a Fare Paying Passenger?
Yes
No

Do you Have Similar Policy with Other Insurance Companies?
Yes
No

If Yes to any of the three (3) questions above, Please Give Details:

Have you Ever Claimed from any Insurer for the Contingency to be Insured?
Yes
No

If Yes, Give Name of the Insurer with which the Claim was Made:

Amount of the Loss:

Scale of Benefits Required: (Please State the Level of Benefits you Require for G.P.A Only):

Death Benefit:

P.D Benefit:

T.T.D Benefit:

M/Expenses:

Other Extended Benefits (Please State):

COMPANY DETAILS

Date of Registration:

Incorporation No:

Nature of Business:

Name of Bankers:

Address of Bankers:

Name of Auditors:

Address of Auditors:

Names/Addresses of Company Directors:

1.) Names:

Address

2.) Names:

Address

3.) Names:

Address

PLEASE PROVIDE THE FOLLOWING * Please provide photocopies and bring along the original documents for confirmation.

1) A Copy of your Schedule of Employee Data (with their estimated annual earnings).

2) Copy of Authorization to Operate from Relevant Regulatory Bodies

3) Certificate of Incorporation/Registration

4) Form CO2

5) Form CO7

6) Memorandum & Article of Association

DECLARATION

I/We, hereby declare that the above particulars and answers are true and complete in every respect, and that no
information has been suppressed or withheld. I/We further declare that if such statements and particulars are in the writing
of any person other than myself/ourselves such person shall be deemed to have been my/our agent for the purpose of filling
the form.

Name of Proposer:

Signature:

Date:

Agent/Company Representative: