PERSONAL-ACCIDENT

PROPOSAL AND DECLARATION FORM FOR PERSONAL ACCIDENT INSURANCE
State whether
FULL NAME OF PROPOSER

First NameLast Name
ADDRESS
EMail
BUSINESS OR OCCUPATION
NATIONALITY
Date of Birth

MonthDayYear
Date
Height
Weight
Marital Status
State if you are

engage in commercial or clerical duties onlyMaster working or workman (without machinery)Master working or workman (machinery)
For what accidents have you received medical attention during the past three(3) years? Give full particulars
Nature
Date

MonthDayYear
Date
Duartion
Do you engage in any of the following activities?

Motor CyclingFoot ballingBig game huntingparachutingDivingMining
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?
decline or required special terms to insure you? (a)
cancelled or refused to continue your insurance (b)
increases your premium on renewal? (c)
State the amount of benefit required for :-Death GH¢
Permanent Disablement GH¢
Temporal Total Disablement GH¢
Medical Expenses GH¢
BENEFICIARIES IN CASE OF DEATH
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
No
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