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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.

1.
  Company Name * Company Name is required.  
  Contact Person * Contact Person is required.  
  Full Postal / Contact Address  
  Phone Number (s)  
  GSM Number  
  Fax Number(If available)  
  E-mail Address * Email address is required.Invalid format.  
         
  Anniversary Date  
  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
1 Are all the persons to be insured in a good state of health and free from physical defects or infirmity? If not give particulars?
2 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
3 Are you or have you ever been insured for these risks? If so, with which insurers and why was the Insurance discontinued?
4.
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 taht I/We have not withheld any material informatio, and I/We hereby agree to tgive notice tot he under mentioned company of any variation i the profession,coccupation or health fo any of the persons to be inssured immediatey such inforation comes to my/our knowledge. I/We furhter agreet 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 condtions prescribed by the Company.


Dated 07-02-2012
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
 
        BENEFITS TO BE INSURED
NAME IN FULL
(Mr,Mrs or Miss)
 AGE OCCUPATION(S)
and/Class-see Prospectus		 Estimated Total Wages, Salaries and other earnings A
Death		 B
Permanent Disablement		 C
Temporary Disablement		 D
Medical Expenses
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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