PROPOSAL FORM FOR GROUP PERSONAL ACCIDENT INSURANCE

PROPOSAL FORM FOR GROUP PERSONAL ACCIDENT INSURANCE
FULL NAME OF PROPOSER
ADDRESS
EMAIL
example@example.com
OCCUPATIONBUSINESS
TELEPHONE NO.
FAX
DATE OF BIRTH

MonthDayYear
Date
Employees/members to be insured (categories wise)
3.Please attach a list of insured members with all details: Name, Age, Gender, Nationality, Position and Salary.
4. Total Number of individuals to be insured
5. Total Sum Insured of all members to be insured
6 Period of Cover / insurance required (If not Annual please advise the period)
Do your employees engage in any other type of hazardous activities? If so, give details.
Do they have or have they ever had accident insurance, if so where? If yes give Company and sum assured?
Has any insurer ever
(a) decline or required special terms to insure you?
(b) cancelled or refused to continue your insurance?
(c) increases your premium on renewal?
State the amount of benefit required for:- - Death GHC
Permanent Disablement GHC
Temporal Total Disablement GHC
Medical Expenses GHC
11.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
Should be Empty:

Has any insurer ever