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PROPOSAL FOR "GROUP ACCIDENT" INSURANCE

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

For Corporate Organisation Click Here.

	Surname *	Surname is required.
	First Name *	First Name is required.
	Middle Name
	Title	Please select an item.
	Full Postal / Contact Address
	Phone Number (s)
	GSM Number
	Fax Number(If available)
	E-mail Address *	Email is required.

	We can send alerts to you for renewal of your policy(ies). Please confirm how you would prefer to recieve your alert.

PROPERTY TO BE INSURED

Are all the persons to be insured in a good state of health and free from physical defects or infirmity? If not give particulars?

Please indicate

a)the extent to which any of the insured persons will use aviation for travel
b) any other circumstance material to the risks to be insured

Are you or have you ever been insured for these risks? If so, with which insurers and why was the Insurance discontinued?

Please indicate the number and brief particulars of accidents which occured during the past Years

Please describe any special modifications fo the cover you wish included

DECLARATION. I herby warrant and declare the truth of all the above statement and that I/We have not withheld any material information, and I/We hereby agree to give notice to the under mentioned company of any variation with the profession,coccupation or health of any of the persons to be insured immediately such inforation comes to my/our knowledge. I/We further agree that this Declaration shall be the basis of the contract between me/us and Leadway Assurance Company Limited and to accept policy subject to terms exceptions and conditions prescribed by the Company.

Dated 30-07-2010
Insurance to commence to be revewed annually on

No Insurance is in force until the Proposal has been accepted by Company and a Premium or a Deposit paid except as provided by the Official covering Note issued by the Company.

Agency Policy No G.P.A

SCHEDULE OF PERSONES TO BE INSURED

Please note that details of all items to be insured and their respective sums should be sent by fax or mail to our Corporate Office for further processing.

I agree with all the terms and conditions. click here to read terms and conditions.

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