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