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Public Liability Proposal Form

This document contains a public liability insurance proposal form from AXA Mansard Insurance PLC. The form collects information about an applicant such as their name, address, bank details, occupation, and risk details. It asks questions about the applicant's business activities and any past insurance claims to determine eligibility. If accepted, the form would serve as the basis for a public liability insurance contract between the applicant and AXA Mansard Insurance PLC.

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Jide Seyi
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© © All Rights Reserved
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426 views3 pages

Public Liability Proposal Form

This document contains a public liability insurance proposal form from AXA Mansard Insurance PLC. The form collects information about an applicant such as their name, address, bank details, occupation, and risk details. It asks questions about the applicant's business activities and any past insurance claims to determine eligibility. If accepted, the form would serve as the basis for a public liability insurance contract between the applicant and AXA Mansard Insurance PLC.

Uploaded by

Jide Seyi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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AXA MANSARD INSURANCE PLC RC133276

Santa Clara Court


Plot 1412, Ahmadu Bello Way, P.M.B. Box 80015, Adeola
Odeku, Victoria Island, Lagos
“AN INDIVIDUAL WHO ASSISTS AN APPLICANT TO COMPLETE THIS PROPOSAL FORM
FOR INSURANCE SHALL BE DEEMED TO HAVE DONE SO AS THE AGENT OF THE APPLICANT”

Public Liability Insurance Prospectus


This policy covers financial damages and legal expenses arising out of:
 Accidental bodily injury to or illness of any person (whether or not death results)
 Accidental loss or damage to property
occurring during the period of insurance and in connection with the business carried on at
any place described in the schedule.
Public Liability Insurance Proposal Form
*Please fill or tick where applicable
Name:

Contact Address

Telephone No(s)_______________________________________ Fax No._______________________

E-mail_______________________________ Website: ______________________________________

Occupation: _______________________________________________________________________

Bank Account Number:__________________ Bank Name___________________________

BVN_____________ Nationality____________________ Place of Birth_________________

Tax Identification Number__________ Resident Permit (For Non Residents):____________

Country of Dual Citizenship:___________________________ Foreign Mailing

Address_________________________________________________________________

Means of Identification: ______________________________ ID No:___________________________

Period of Insurance: From: __________________________To:_______________________________

Risk Location(s): ____________________________________________________________________


__________________________________________________________________________________
Use of premises: ____________________________________________________________________

Annual Turnover: N ________________________________________________

Limit of Indemnity: Anyone Occurrence: N _______________________________

Anyone Period of Insurance: N__________________________

Expected Premium: N _____________________Source of Funds: ____________________________

Bankers: ___________________________________________________________________

Please Note “No Cash Payment”:


Kindly ensure all payments are made directly into AXA Mansard’s designated corporate account account(s). All cash
payments MUST be made in person, as the company shall not be held liable for cash payments made to/through other
parties apart from NAICOM licensed insurance brokers. AMIPLC/P&C/PLPF/09/2016/V1.2
PUBLIC LIABILITY
Are any workers involved in manual works in connection with installation,
erection, repair, maintenance, testing, demolition or construction outside Yes No
insured’s premises?
Are any workers involved in works at great heights (above 30 feet above
floor or ground level) Yes No

Are any workers involved in works involving explosives, dangerous or


Yes No
toxic chemicals?
Are any workers involved in excavation works, work in manholes or Yes No
tunnels or any similar activity?
Are any workers involved in using heavy industrial machines that involve Yes No
cutting, pressing, grinding etc?
Are any workers involved in lifting or hoisting operations, especially in Yes No
public areas?
Do you undertake any work away from your premises? Yes No
If yes, please give details:_____________________________________
__________________________________________________________

Does your business create any trade waste? Yes No

If yes, please give details of waste and methods of disposal:___________


___________________________________________________________

Are any workers required to work onboard vessels? Yes No

If yes, what is the maximum no. of employees on board any vessel any
one time? ________

Will there be any diving &/or related underwater activities pertaining to Yes No
your business?
Please provide details of any Hazardous Goods that are stored at your Yes No
premises:
Do you employ the services of contractors, sub-contractors Yes No

If yes to any, are they required to carry their own Public/product Liability
Insurance?
Does your business create any trade waste?
Yes No
If yes, please give details of waste and methods of disposal:__________
__________________________________________________________

Is there any insurance in force covering the same exposure for the same
period of insurance being proposed? If yes, please state: Yes No

Name of Insurer: _______________________________________


Limit of Indemnity (N): ___________________________________

Has any Insurance Company ever refused your Public/product Liability


Insurance Proposal or refused to renew your Policy? Yes No

Please Note “No Cash Payment”:


Kindly ensure all payments are made directly into AXA Mansard’s designated corporate account account(s). All cash
payments MUST be made in person, as the company shall not be held liable for cash payments made to/through other
parties apart from NAICOM licensed insurance brokers. AMIPLC/P&C/PLPF/09/2016/V1.2
Has your insurance been cancelled solely or in part due to a breach of
Yes No
premium payment warranty in the last 12 months?
PRODUCT LIABILITY
*Attach any brochures or other related material for each product
Intended Manufacture Source country (if
Product
Use Turnover Imported)

Do you manufacture, construct, erect, install, repair, service, treat, sell,


Yes No
supply or distribute any products?
Please provide details of quality control procedures in place: ________
Yes No
________________________________________________________

Are your products subject to any Standards? Yes No


If yes please give details:

Are you or is your product required to be compliant with any other Yes No
industry standard or regulation?

If yes please give details: __________________________________

Have you suffered any of loss (es) in the past: Yes No


If yes give details
Amount
Year Insurer Claimant Nature of Problem Paid/Outstanding
(N)

DECLARATION
I/We warranted that the above statements are true and complete and I/We agree that this
proposal shall be the basis of the contract between me/us and the Company. I/We agree to
accept a policy in the Company’s usual form for this class of insurance
Name: ___________________________________________________________________

Signature/Initials: _________________________________Date:_____________________
OFFICIAL USE ONLY
Broker/Agent/BA: ___________________________________________________________

SBU/Hub/Spoke: ___________________________________________________________

Client’s Risk Category: ___________________ Accept Decline

Please Note “No Cash Payment”:


Kindly ensure all payments are made directly into AXA Mansard’s designated corporate account account(s). All cash
payments MUST be made in person, as the company shall not be held liable for cash payments made to/through other
parties apart from NAICOM licensed insurance brokers. AMIPLC/P&C/PLPF/09/2016/V1.2

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