PAX INSURANCE COMPANY

P.O BOX 7030KAMPALA

TEL 414 233096/89, 312 266163 FAX 414 233141

PROPOSAL FOR GROUP PERSONAL ACCIDENT INSURANCE

PLEASE ANSWER ALL QUESTIONS FULLY: TICKS OR DASHES ARE NOT SUFFICIENT

A. DETAILS OF PROPOSER

Full Name of Proposer (in Block Letters)……………………………………………………………………………

Full Postal Address: P.O. Box……………………………………………………………………………………….

Plot No:…………………… Street:………………………………………….. Tel No…………………………….

Trade or Business:…………………………………………………………………………………………………….

  1. Policy to date from……………………………………. To:………………………………..(……….Months)
  2. Geographical Area: Uganda
  3. Description of Business / Profession:…………………………………………………………………………
  4. General Information.
  1. State the number of years you have been established in the above business………………………………….
  2. State the number of individuals to be covered……………………… Annual Earnings………………………
  3. Do you handle or use radio isotopes radioactive substances, or other sources of ionizing, radiation/ Yes/No…

If yes, give details………………………………………………………………………………………………

  1. a) Are you at present insured or have you ever proposed for Group Personal Accident Insurance with any Company? Yes/No………….. If yes, give details…………………………………………………………

…………………………………………………………………………………………………………………

b)Have such proposals or renewals ever been declined or withdrawn? Yes/No……………… If yes, give details………………………………………………………………………………………………………

c)Have increased rates been required for such proposals? Yes/No……………… If yes, give details………………………………………………………………………………………………………

d)Are you at present insured or have you ever proposed for…………………………………………………

  1. Is any of the persons to be Insured engaged in hazardous or dangerous sports? If so give details………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
  1. Schedule of employees to be covered (Attach if possible)
  2. Benefits to be Covered:

a)Accidental death / Permanent total disability:………………………………………………….Per person.

b)Temporary permanent disability:………………………………………………………………..Per person.

c)Temporary partial disability:…………………………………………………………………….Per person.

d)Accident medical reimbursement:……………………………………………………………….Per person.

e)Last / Burial Expense: …………………………………………………………………………..per Person.

H.NOTE

The Insurance applied for shall be effective from the Data Application, But only:

a)If the application is unconditionally approved of by the Company as an acceptable risk under the Company’s rules and

b)If this receipt is for the whole amount of the First Annual Premium and such amount been paid to the company.

I.Declaration

I/We warrant the truth of the above answers and statements and declare that I/we have not withheld, misstated or misrepresented any fact which might be considered material to this insurance. I/We further declare and agree that this declaration shall be the basis of the contract between me/us and PAX Insurance Company Ltd.

I/We accept the levels of cover chosen and will not except any additional payment from Excel Insurance Company Ltd. for claims exceeding the sums insured.

Name of Proposer:………………………………… Signature…………………………… Date……………………

J.COMMENTS AND REMARKS BY THE MARKETING EXECUTIVE / CONTACT (INCLUDING

HIS KNOWLEDGE OF THE CLIENT)

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Name………………………………………….. Signature…………………………. Date………………….

FOR OFFICIAL USE ONLY

K. COMMENTS AND REMARKS BY SENIOR UNDERWRITER

(Assessment of risk, Rates to be applied and approval)

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Name:……………………………………… Signature:……………………… Date:……………………….

L. MANAGING DIRECTOR’S COMMENTS

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Name:…………………………………….. Signature……………………………. Date:………………………..

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