PERSONAL-ACCIDENT

PROPOSAL AND DECLARATION FORM FOR PERSONAL ACCIDENT INSURANCE
State whether

Mr.Mrs.Miss.Dr.Other titile
Full Name Of Proposer

First NameLast Name
Address
E-Mail
google@google.com
Business Or Occupation
Nationality
Date of Birth

MonthDayYear
Date
Height
Weight
Marital Status
State if you are
engage in commercial or clerical duties only
master working or workman (without machinery)
master working or workman (with machinery)
For what accidents have you received medical attention during the past three(3) years? Give full particulars
Nature of Accident Date

MonthDayYear
Date
Duartion
Do you engage in any of the following activities? (a) Motor Cycling(b) Foot balling
Do you engage in any of the following activities?

Motor cyclingFootballingBig game huntingparachutingDrivingMining
Do you engage any other type of hazardous activities? If so, give details.
Have you any intention going outside your country of residence if so where
Do you have or have you ever had accident insurance, if so where? If yes give Company and sum assured?
Do you have or have you ever had accident insurance, if so where? If yes give Company and sum assured?
decline or required special terms to insure you?

YesNo
cancelled or refused to continue your insurance?

YesNo
Increases your premium on renewal?

YesNo
Death (GH¢)
Permanent (GH¢)
Temporal Total Disablement (GH¢)
Medical Expenses (GH¢)
BENEFICIARIES IN CASE OF DEATH AGE NAME
Name
Age
Relationship
Sex
I/ We warrant that the above statements and particulars are true and I We hereby agree that this Declaration shall be held to be a promissory and of continuing effect and shall form the basis of and be deemed to be incorporate in the Contract between me/us and PHOENIX INSURANCE COMPANY and I/We are willing to accept a Policy subject to the Terms prescribed by the company.
Date

MonthDayYear
Date
Signature of Proposer

Clear
Agent
Phone Number
020-000-0000
The LIABILITY of the Company does not commence until Premium has been paid and official receipt issued
Should be Empty:

PROPOSAL AND DECLARATION FORM FOR PERSONAL ACCIDENT INSURANCE

State if you are

For what accidents have you received medical attention during the past three(3) years? Give full particulars