EMPLOYERS LIABILTY (COMMON LAW) INSURANCE PROPOSAL FORM

Summary of Cover

Indemnity to the employer against legal liability under common law for damages and claimants costs and expenses of litigation in
respect of awards for bodily injury by accident or disease caused to employees during the period of insurance and arising out of and in
the course of that employment by the Employer in the Business and directly related to breach of common law or statutory duty by the
Employer and in addition indemnity in respect of all costs and expenses incurred by the Employer with the Company’s written consent
subject to the terms, jurisdiction clause, exceptions, conditions and warranties of the Company’s Employers Liability (Common Law)
Policy,

Name in full ______________________________________________________________________________________

PIN Number_____________________________________________________________Agency _________________

Postal Address _____________________________________Postal Code _____________________

Town ______________

Telephone Number(s) ____________________________ Fax Number____________________________

Email Address __________________________________________________________________________________

Physical Address / Location _________________________________________________________________________________

Nature of Business / Occupation ______________________________________________________________________________

Period of Insurance required:

From _______________________To________________________________

All questions must be answered fully Ticks or Dashes are not sufficient.

Please note that the truth of the statements and answers in the proposal are conditions precedent to liability.

1.(a) Does any law or regulation governing the (i) Yes/No ………………………
conduct or maintenance of premises apply to your If so, name such laws and regulations.
premises? ______________________________________________________
______________________________________________________
______________________________________________________

(ii) Have you carried out all obligations imposed on you by such
laws and regulations? Yes/No
______________________________________________________

2. (a) Do you have any circular saws or other (a) Yes/No _________________________ if yes, give details
machinery driven by steam, gas, water , ______________________________________________________
electricity or other mechanical power? ______________________________________________________
(b) Do you have any boilers? (b) Yes/No __________________________ if yes, give details
______________________________________________________
(c) Are your ways, works and plant properly fenced ______________________________________________________
and guarded and otherwise in good order and © Yes/No…………………
condition?
3. Do you use acids, gases, chemicals or Yes/No __________________________________
explosives? If yes, give details
______________________________________________________
______________________________________________________

4. Do you handle or use radio isotopes radioactive Yes/No ___________________________________

substances, or other sources of ionising radiations? If yes, give details
______________________________________________________
______________________________________________________

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 5.(a) Are you presently insured for Work Injury (a) If so, please state policy number _________________________
Benefits ? _____________________and name of Insurer(s)______________
______________________________________________________
(b) Are you at present insured or have you ever
proposed for any insurance in respect of your legal (b) If so, please state policy number _________________________
liability under common law to your employees? _____________________and name of Insurer(s)______________
______________________________________________________
(c) Have such proposals or renewals ever been
declined or withdrawn? (c) If, so please give reasons ______________________________
______________________________________________________
(d) Have increased rates been required for such and name of Insurer(s) __________________________________
proposals or renewals? (d)Yes/No _____________________________________________
If yes, give details____________________________________
__________________________________________

6. Do you have any employee with pre-existing

medical condition? Yes/No _________________________________

7. (a) Do you have any employees who are Yes/No

apprentices or trainees in your organisation? If Yes State how many ______________________ and give the
estimated annual wages payable to a similar person(s) with five
years experience………………………………………..

EMPLOYEES BEING WORKERS AS DEFINED BY SECTION 5 OF THE WORK INJURY BENEFITS ACT, 2007.

For official use only

Names/number of Description of Estimated Annual Rate Premium Classification
employees Occupation Salaries / Wages
And Other
Earning On
Which Premium
Is Based

For additional occupations please use a supplementary sheet.

Please note that it is a condition of this Policy that the Estimated Annual Wages, Salaries and other Earnings is required
to be certified annually by your Auditors within three months of the expiry date of the period of Insurance.

7. Give the following information in respect of the past three years.

Year Wages, Salaries and Number of Accidents Claims

Other Earnings to your employees
(whether or not Settled Outstanding
Involving Claims) Number Cost Number Cost

8. Limits of Liability

Please state the option selected A B C D

A B C D
Any one person Kshs. 2,000,000 Kshs. 4,000,000 Kshs. 6,000,000 Kshs. 8,000,000
Any one occurrence Kshs. 10,000,000 Kshs. 15,000,000 Kshs. 20,000,000 Kshs. 25,000,000
Any one year Kshs. 20,000,000 Kshs. 30,000,000 Kshs. 40,000,000 Kshs. 50,000,000

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I/we the undersigned desire to effect insurance in terms of the policy to be issued by the Company against Liability to my/our
Employees within the meaning of the Work Injury Benefits Act, 2007. I/we agree to keep detailed records of all persons employed
(including Identification documents) and to submit within three months after the end of each period of Insurance a statement in the form
required by the Company of all wages, salaries, other earnings, which shall be duly certified by our Auditors and to pay premium on any
amount in excess of the amount estimated above. I/we hereby declare that all the above statements and particulars are true and I/we
have not suppressed, misrepresented or incorrectly stated any material fact, and that I/we have fairly estimated the total amount of
Wages, salaries and other earnings and I/we agree that this declaration shall be the basis of the contract between me/us and the
Company.

Signing this proposal form does not bind the proposer or underwriter to accept this insurance.

Executed at this______ day of__________20____

For and on behalf of:

Name: __________________________________

Signature: _______________________________ (If Corporate): Name & Designation of Contact Person:………………………………….