Workmen's CompensationsProposal

Personal Details

Risk Details

Claims Details

General Policy Details

Personal Details

Proposer Type

Are You a Shareholder?

Intermediary

Agent Name/Code

Binder

ID Type

ID Number

TIN Number

Proposer First Name

Proposer Middle Name

Proposer Last Name

Is there any Care of/Account of/and?

Please specify name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

Is the insurance being purchased for self? (if no, state your details)

First Name

Middle Name

Last Name

Applicant Contact & Other Details

Contact Details

Mobile No.

Telephone No.

Fax No.

Region/City

Zone/Sub City

Woreda/District

Kebele

P.O. Box No.

H.No.

Email Address

Which Berhan Insurance S.C. branch do you want to be served from?

Physical Address

Do you have a Motor Commercial from Berhan Insurance S.C.?

Do you have any employee with any pre- existing medical condition?

Name

Occupation

Description of medical condition

Type of Income

Estimated Salary (Per Employee)

Estimated Annual Salary (Per Employee)

Occupation Description

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Total Estimated Annual Salary (Max Total Estimated Annual Salary : 999999999999)

Do you have any employee who is an Apprentice or Trainee?

Name

Occupation

Type of Income

Estimated Salary (Per Employee)

Estimated Annual Salary (Per Employee)

Occupation Description

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Total Estimated Annual Salary (Max Total Estimated Annual Salary : 999999999999)

Human Resource Contact Information

Mobile No.

Email address

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Do you have any other policy from Berhan Insurance S.C.?

Claim history

Did you have any claim in last 3 years

Year

Wages, salaries and other earnings

Claim settled total

Number of accident to your employees(whether or not involving claims)

Claim outstanding number

Claim outstanding cost

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General Policy Details

Are you now or have you ever been insured for this type of policy ?

Has any insurance company ever

Declined your proposal ?

Cancelled or refused to renew your policy?

Required an increased premium or imposed special conditions?

Declined your claim?

Required you to carry the first portion of any loss?

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 3 years

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss

DECLARATION AND CONSENT | Please Read Carefully *

I the undersigned declare that the vehicle(s) described (is/are) in good condition and will continue to be maintained and I hereby warrant that the above statement and particulars are true and I hereby agree that declaration shall be deemed to be of a promissory nature and effect and the basis of the contract between me and the Company and that I have not withheld any important information which should be communicated to the Company and that I am willing to accept a policy subject to the terms, conditions and exceptions therein and to pay the premium agreed upon.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Berhan Insurance S.C. to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)

Workmen's Compensations Proposal

Personal Details

Contact Details

Period of Insurance

Corporate Headquarter Detail

Do you handle or use any of the following at your Premises?

Employee Details

Do you Require to Extend:

Extensions:

Additional Benefits:

Human Resource Contact Information

Claim history

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION AND CONSENT | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *