Workmen's Compesation Insurance Form

WORKMEN'S COMPESATION INSURANCE PROPOSAL FORM DownLoad Proposal Form

Full Name of Proposer

Business Address

Proposer's Trade or Occupation

Particulars of Work

Description of Employers	Estimated Number of employers	Cash	Value of food,etc in addition to Money earnings	Total	Rate Percent	Premium =N= K	Classification No
Clerical Staff
Commercial Travellers
Apprentices and Articles Pupils
Employees engaged with Woodworking,Machinery including Machinist & Machinist,Labourers
TOTAL PREMIUM

Other Viz :

(i) Total amount of wages, salaries and other earnings paid by me/us to the above mentioned employed in the past twelve months

(ii) Do you require indemnity in respect of Medical Expenses under Workmen's Compesation Decree?

Yes No

(iii) If you require indemnity in respect of Medical Expenses under the Workmen's Compesation Decree to the Workman of subcontractor please state:

(a) Name of Contractor

(b) Nature of Work Subject

(d) In cases for which the contract is for labour only state amount of contract

Schedules B & C
Employess NOT within the scope of the Workmen's Decree may be insured

1.To secure benefit as though they were Workmen;as defined in the Decree (Schedule B) or
2.To secure indemnity in respect of liability at Common Law only (Schedule C).
NOTE: If Insurance is under either of these Schedules ALL such employees must be included in the Schedule selected.

Description Of Employees	Estimated Number Of Employees	Cash	Value of food,etc in addition to money earnings	Total	Rate Percent	PremiunmN K	Classification No
SCHEDULE B Benefit of Decree
SCHEDULE C Common Law Liability only
TOTAL PREMIUM

The total amount of wages, salaries and other earning paid by me/us to the above mentioned during the past twelve months was:

Do you require indemnity of Medical Expenses under the Workmen's Compensation Degree?

Total Provisional Annual Premium

General Questions

Please Answer Yes OR No

Does the attached Schedule A include:

All person in your service?	Yes No	All your Sub-Contractors	Yes No
Are your machinery,plant and ways properly fence snd guarded and in good order or condition?	Yes No	Give particulars of any circular saws or other machinery driven by stream,gas,water,electricity or other mechanical power	Yes No
Do your premises come within the meaning of any Decree or Regulation governing of the conduct or maintenance of such premises?	Yes No	If YES, name such Decree or Regulation
Have you carried out all the obligation Imposed you by such Decree or Regulation?	Yes No	If the insurance is to extend to the Employees not within the scope of the (See Schedule B & C) do those Schedule include all such persons in your service

INSURANCE HISTORY

ANSWER YES or NO

Are you at present insured or have you ever proposed for and an insurance in respect of your liability to your employers?

Yes No

Has any insurer in respect of your liabilty to your employees ever

Declined your proposal?

Yes No

Imposed any special terms?

Yes No

Cancelled or refused to renew your policy?

Yes No

If YES to any question above,please give details

State hereunder the amount of wages paid and give particulars of the number of accidents to your employees incidental to their occupation during the past three years

Year	wages	Number	FATAL	PERMANENT DISABLEMENT		TEMPORARY DISABLEMENT ONLY
Year	wages	Number	Compesational paid to date	Number	Compesational paid to date	Number	Compesational paid to date

CLAIMS	STILL UNSETTLED	CLAIMS	STILL UNSETTLED	CLAIMS	STILL UNSETTLED
Number	Estimated further cost	Number	Estimated further cost	Number	Estimated further cost

Are there any additional facts likely to affect the proposed insurance which should be disclosed to the Underwriters?

Yes No

If YES, give details

DECLARATION

I/We the undersigned, desire to efect an insurance as above stated in terms of the Policy to be issue by the Company. I/We agree to keep a proper Wages Record and to render at the end of each period of insurance a statement in the form required by the Company of all wages actually paid and to pay premium on any wages paid in excess of the amount estimated above. I/We hereby declare that all the above statements and particulars which I/We have read over and checked are true, that I/We have not suppressed, misrepresented or misstated any basis of the contract between me/us total wages and salaries expenditure and I/We agree that this declaration shall be the basis of the contract between me/us and CRUSADER INSURANCE (NIGERIA) PLC.

Agree Disagree