Employer’s Liability Insurance Proposal Form

EMPLOYER'S LIABILITY INSURANCE PROPOSAL FORM


In completing the Proposal Form please ensure that questions are answered fully and accurately and where necessary schedules giving further explanation are provided.

IMPORTANT NOTICE CONCERNING DISCLOSURE

It is your duty to disclose all material facts to Underwriters. A material fact is one that is likely to influence an Underwriter’s judgement and acceptance of your proposal. If your proposal is a renewal of an existing policy, it should also include any change in facts previously advised to Underwriters. If you are in any doubt as to whether or not facts are considered material, you should disclose them.


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(f) Period of Insurance:


SCHEDULE

PLEASE ENTER BELOW THE WAGES, SALARIES AND OTHER EARNINGS OF ALL EMPLOYEES, INCLUDING MEMBERS OF THE PROPOSER'S FAMILY EMPLOYED BY HIM

Clerical, Supervisory or Managerial employees (no manual work involved)

Employees engaged with Woodworking Machinery, including Machinists and Machinists Labourers

Note: Employees who work with wood-working machinery are restricted to the use of Lathes, Fret-saws, Boring Machines, Sanding Machines and Mechanically-driven portable tools applied to the work by hand other than Pendulum and Swing Saws to be included with "All other employees".

All other employees (List by occupation)


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4. Do you manufacture, dress, handle or use:


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9. Please state the number of accidents to your employees and cases of disease related to their occupation during the past three (3) years.


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SIGNING THIS PROPOSAL DOES NOT BIND THE PROPOSER TO COMPLETE THIS INSURANCE

Declaration

I/We declare that the statements and particulars in this proposal are true and that no material facts have mis-stated or suppressed after enquiry. I agree that this proposal, together with any other information supplied shall form the basis of any contract of insurance effected thereon. I/We undertake to inform the Insurers of any material alteration to those facts occurring before the completion of the contract of insurance.

Signed by Proposer