PROPOSAL FORM FOR COMBINED LIABILITY INSURANCE
IMPORTANT INFORMATION:

1. An agent who assists an applicant to complete an application or proposal form for insurance shall be deemed to have done so as the
    agent of the applicant in accordance with section 54(2), Insurance Act, 2003.

2. The liability of the Company does not commence until this application is accepted and the premium is paid in accordance with section 50(1) of
    Insurance Act, 2003

SECTION I:



















SECTION II:

     
     
     



 

Shareholders’ Funds

   
     
       
DETAILS OF DIRECTORS/PRINCIPAL OFFICERS (Click the + sign to Add Directors)    +

KINDLY ATTACH THE FOLLOWING DOCUMENTS:





SECTION III:

Has any employee or any director ever been convicted or charged with criminal offence
     
     
If yes, give details in a :