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LIABILITY INSURANCE PROPOSAL/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:
Surname:
First Name:
Middle Name:
Title:
Mr.
Mrs.
Ms
Other
Gender:
Male
Female
Date of Birth:
Occupation/Business:
Tel. No.:
Email Address:
Business Address:
Period of Insurance:
From
To
STATE THE ESTIMATED TOTAL ANNUAL WAGES FOR (INCLUDING REMUNERATION OF WORKING PARTNERS AND DIRECTORS):
Own Premises:
Work Done Elsewhere:
STATE THE ESTIMATED TOTAL ANNUAL PAYMENTS TO SUB-CONTRACTORS ON:
Own Premises:
Work Done Elsewhere:
Are All the Premises in Good State of Repair?
Yes
No
Do you Have Vehicles or Cycles Which are not Power Driven?
Yes
No
Do you Have Good Lifts, Cranes or Hoists?
Yes
No
Are Such Lifts, Cranes or Hoists Regularly Inspected to Meet Statutory Requirements?
Yes
No
By Whom are the Lifts, Cranes or Hoists Inspected?
Give Details of any Mobile Plant and/or Vehicle Not Licensed for Road Us:
State What Acids, Gases, Chemicals, Explosives or Radioactive Materials that May be Used and to What Extent:
Type of Cover Required:
Limit Per Loss:
Limit Per Period:
Public Liability Insurance
Product Liability Insurance
Professional Indemnity
General 3rd Party Liability Insurance
Type of Residence:
Owner
Tenant
How Long has this been your Place of Residence?
No. of Years
No. of Months
INSURANCE HISTORY
Have you Ever been Insured against Liability Risks?
Yes
No
HAS ANY INSURANCE COMPANY OR UNDERWRITER EVER
Cancelled your Policy?
Yes
No
Declined to Insure you?
Yes
No
Refused to Renew your Policy?
Yes
No
Imposed any Special Terms?
Yes
No
Declined any Claim?
Yes
No
If the Answer to any of these is Yes, Please Give Detail:
SOCIAL AND POLITICAL ACTIVITIES
What Social/Membership Club do you Belong to?
Do you or your Spouse Belong to any Political or Pressure Group?
Yes
No
Does any of your Close Relation Belong to any Political or Pressure Group?
Yes
No
If Yes to these items, Tick as Appropriate
Parent
Siblings
Spouse
In Law
Other
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) Name
Address:
2) Name
Address:
DOCUMENTS TO BE SUBMITTED:
* Please provide photocopies and also bring along original copies of the documents for confirmation.
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