Workmen s Compensation/Employer s Liability Insurance

Transcription

1 Workmen s Compensation/Employer s Liability Insurance Proposal Form ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law No. (4) of 1972, and it is governed by the provisions of the UAE Federal Law No. (6) of 2007 Establishment of the Insurance Authority & Organization of its Operations, with Registration No. (1). Completing this form In order to apply for this insurance, please complete all parts of this proposal form and the annexures, if any. You must provide full, accurate, and true answers to all questions listed below. Material facts which you know or ought to know should be fully and accurately disclosed. Failure to do so may result in rejecting your claim and/or terminating the insurance policy from inception. If you are in any doubt about what you should disclose, please do not hesitate to contact us. A material fact is one that would influence our decision whether to offer you insurance or the terms which we offer. If the space provided is inadequate, please provide details using an additional information sheet, signed and dated. Your insurance does not commence when you sign the proposal. Your cover will only commence once we have reviewed the proposal form and confirmed cover in writing. Please keep a copy of this proposal form for your record along with any correspondence/ information provided to us and policies/endorsements that are issued to you subsequently. 1/6

2 1. General information a. Names of companies proposed to be insured (including all associated and/or subsidiary companies): b. Address: (Please show the address required on the policy): P.O. Box: Country: City: Contact person s name: Phone number: Mobile number: Fax number: address: c. Please describe the nature of the business operations and identify any special features carried out by the proposer: d. If this proposal is for a single project, please detail your scope of work for this project: 2. Insurance details a. Period of insurance required: i) Annual cover Twelve (12) months commencing from the date to be advised (dd/mm/yy): ii) Project cover Commencing from the date to be advised (dd/mm/yy) to the date to be advised (dd/mm/yy): b. Number of employees to be covered and their occupation: c. Estimated payroll of employees/laborers engaged in this business/project: i) Please specify if you are taking this insurance for all employees in your service? Yes No If not, please confirm which category of employee is not covered? 2/6

3 2. Insurance details (continued) Please provide the split between manual/non-manual work (Do not include employees of sub-contractors) Number of employees Basic wages/total wages Location and/or country of operation Manual work Non-manual work (Note: We will consider the declared as basic wages unless specified) ii) Do you propose to include employees of your sub-contractors? Yes No If Yes, please provide names of the sub-contractors, number of employees, with wage split between manual and non-manual work here below: Name of sub-contractor: Number of employees Basic wages/total wages Location and/or country of operation Manual work Non-manual work (Note: We will consider the declared as basic wages unless specified) d. Are there any offshore works involved? Yes No If Yes, please provide details of such offshore work: e. Do you require Employer s Liability? Yes No If Yes, please tick the limit of indemnity required for Employer s Liability Currency: AED USD Euro Any other, please specify: 1,000,000 2,000,000 5,000,000 Any other, please specify: f. Please specify the geographical area required for the insurance cover: 3/6

4 3. Operational details a. Do you provide specific training to your employees on how to perform their respective job? Yes No b. Are all employees acquainted with standard safety procedures? Yes No c. Are the employees provided with safety manuals? Yes No d. Does the insured instruct all workers in proper lifting techniques? Yes No e. Are the employees provided with material-handling aids and encouraged to obtain help where moving extremely heavy objects? Yes No f. Does the insured provide heavy-duty work gloves for all employees performing rigorous manual labor? Yes No g. Are your machinery, plant, and ways properly fenced and guarded and otherwise in good order and condition? Yes No h. Are all machines equipped with emergency stop bars? Yes No i. Are employees who operate process machinery instructed not to wear loose-fitting clothing and to remove all jewelry or accessories which could get caught in an in-running nip point? Yes No j. What is the level of housekeeping in the production area? k. State what acids, gases, chemicals, or explosives will be used and to what extent? 4. Insurance history a. Are you presently insured for Workmen s Compensation Insurance? Yes No If Yes, please give full details of insurer/insurers and cover provided or provide us with a copy of the existing insurance policy: 4/6

5 4. Insurance history (continued) b. In respect of Workmen s Compensation Insurance, has any insurer ever canceled your cover or refused to renew? Yes No If Yes, please give full details: c. List the claims experience for the past five years, whether or not any payment has been made by any other insurance company or third party? Year Amount Outstanding Claims No. of Claims Amount No. of Claims Amount d. Are you aware of any incidents that may result in claims against you? Yes No If Yes, please give full details: 5/6

6 Declaration I/We hereby declare that the statements/information given by me/us in the Proposal Form are full, accurate and true. It is hereby understood and agreed that the statements, answers and particulars provided in this Proposal Form and as per the attachments are the basis on which the insurance policy is being issued/effected. If after the insurance policy is effected, it is found that any fact in the statements, answers or particulars in this Proposal Form is incorrect, untrue, inaccurate, misrepresented or non-disclosed in any material respect, ADNIC shall have no liability under the insurance policy and/or shall have the right to terminate the insurance policy from inception. Name of Proposer: Title: Signature: Stamp: Date: Note: Please note that each page of the proposal form should be signed by the Proposer or its legal representative 6/6