EMPLOYERS LIABILITY INSURANCE PROPOSAL FORM

Unless all material facts are disclosed, this insurance could be invalidated. Material Facts are those facts an Insurer would regard as likely to influence the acceptance and/or assessment of the Proposal. If you are in any doubt about whether facts are material, you should disclose them. A copy of the completed Proposal Form will be supplied on request but you should keep a record (including copies of letters) of all information supplied to us for the purposes of entering into this contract. A specimen Policy is available on request.

DATE INSURANCE IS TO BEGIN (which cannot be before the proposal is accepted by the Insurers)

EXPIRY DATE

Name of Proposer:

NIB/TIN#:

Postal Address:

E-mail:

Telephone (Office):

Telephone (Mobile):

Telephone (Other):

Details of loss being reported:

Limit of Indemnity required:

Per occurrence and in the aggregate inclusive of costs and expenses.

SCHEDULE OF EMPLOYEES TO BE INSURED

Guidance Notes:

All employees of a particular class of occupation must be included.

Estimated earnings (as inserted in Column 2) must include all wages, salaries, bonuses, tips, overtime payments and other special remuneration and the value of food, accommodation and all other allowances in kind.

Woodworking machinists and their labourers – the total earnings of such employees must be included in this item, irrespective of whether they are wholly or partially engaged with such machinery. Employees whose work with woodworking machinery is restricted to the use of lathes, fret saws, boring machines, sanding machines and mechanically or electrically driven portable tools applied to the work by hand (other than saws) should be included under “Other Staff”.

Class of Occupation of Employees

Column 1 Estimated Number of Employees

Column 2 Estimated Annual Earnings

Annual Earnings for the past three years

Year

Clerical Staff

Woodworking Staff See Note c) above

3. Other:

4. Other:

5. Other:

6. Other:

ADDITIONAL DETAILS:

NOTICE IN ACCORDANCE WITH THE DATA PROTECTION ACT

Please note that in accordance with the Data Protection Act 2003, the information supplied when arranging this insurance policy may be shared for insurance purposes and services with other companies and organisations. For full details please refer to the Data Protection Act Statement available from Insurance Management (Bahamas) Ltd.

DECLARATION

I/We declare that the above statements made by me/us or written in answer to the questions on this form on my/our behalf by someone else are to the best of my/our knowledge and belief true and complete, and no material fact has been misrepresented, misstated or withheld. I/We agree that this proposal shall form the basis of the contract between me/us and the Insurers and will be deemed as incorporated in the Policy to be issued.

I/We agree that an electronically transmitted signature affixed to this document shall have the force and effect of an original signature.

I/We understand that no insurance cover is provided until such time as a Binder, Cover Note, or Policy has been issued by the Insurer(s) or their General Agents.

EMPLOYERS LIABILITY INSURANCE PROPOSAL FORM

SCHEDULE OF EMPLOYEES TO BE INSURED

ADDITIONAL DETAILS:

NOTICE IN ACCORDANCE WITH THE DATA PROTECTION ACT

DECLARATION

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