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LIABILITY INSURANCE PROPOSAL/KYC FORM
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:
Date of Birth:
Period of Insurance:
STATE THE ESTIMATED TOTAL ANNUAL WAGES FOR (INCLUDING REMUNERATION OF WORKING PARTNERS AND DIRECTORS):
Work Done Elsewhere:
STATE THE ESTIMATED TOTAL ANNUAL PAYMENTS TO SUB-CONTRACTORS ON:
Work Done Elsewhere:
Are All the Premises in Good State of Repair?
Do you Have Vehicles or Cycles Which are not Power Driven?
Do you Have Good Lifts, Cranes or Hoists?
Are Such Lifts, Cranes or Hoists Regularly Inspected to Meet Statutory Requirements?
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
General 3rd Party Liability Insurance
Type of Residence:
How Long has this been your Place of Residence?
No. of Years
No. of Months
Have you Ever been Insured against Liability Risks?
HAS ANY INSURANCE COMPANY OR UNDERWRITER EVER
Cancelled your Policy?
Declined to Insure you?
Refused to Renew your Policy?
Imposed any Special Terms?
Declined any Claim?
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?
Does any of your Close Relation Belong to any Political or Pressure Group?
If Yes to these items, Tick as Appropriate
Date of Registration:
Nature of Business:
Name of Bankers:
Address of Bankers:
Name of Auditors:
Address of Auditors:
Names/Addresses of Company Directors:
DOCUMENTS TO BE SUBMITTED:
* Please provide photocopies and also bring along original copies of the documents for confirmation.
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