WORKMEN COMPENSATION / EMPLOYER’S LIABILITY PROPOSAL FORM











    LIST OF EMPLOYEES
    Please ATTACH a list of all Employess to be Insured in the format below:

    No: | Full Name | Date of Birth | Designation | Annual Salary




    PREVIOUS CLAIMS HISTORY
    Please ATTACH a list of all previous Claims by any of the employees in the format below:

    No: | Full Name | Type of Claim | Amount


    Only PDF, Excel & Word Files accepted