Professional Indemnity Proposal

Personal Details

Risk Details

General Policy Details

Personal Details

Proposer Type

Intermediary

Select Intermediary branch

Binder

ID Type

Tax Pin Tax Pin

First Name

Middle Name

Last Name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

If insured name or other name

Quotation Validity Period

Contact Details

Mobile No.

Telephone No.

Email Address

Postal Address

Postal Office

Town

County

Region

Earth Quake Zone

Physical Address

Branch

Do you have a Work Injury Benefit Act from Head Office?

Do you have a Fire and Perils from Head Office?

Insurance Start Date

Insurance End Date

Financier Interest

Location of Corporate Headquarter

Name of Building

Name of Street

Area/Estate

City/Town

County

Premises Type

Nature of Business

Specify exactly what business you are involved in

During the Period of Insurance (and for Single Contract) state the following:

Maximum duration of largest Single contract

Employee Details

State the number of employees (not including contractors or subcontractors)

Do you have a system of vetting employees for trustworthiness before employment?

Please Explain

Do you verify validity of identities before engaging them in employment?

Please Explain

Do you conduct formal security guards training for your employees?

Please Explain

What is the Duration of Training In Months

Will you be involved in any of the following activities?

Security work in or around an airport or aircraft landing area or working railways?

Please provide details

Security work in oil, gas, chemical or petrochemical plants?

Please provide details

Security work in mining processing plants?

Please provide details

Security work in Government offices, State Corporation or Parastatals?

Please provide details

Security work in foreign embassies, High Commissions or consulates?

Please provide details

Insurance Details

Limits of liability

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?

Insurance and Loss History

Have you either alone or in partnership or jointly with any other party or any of your directors or office holders

Been charged with or convicted of any criminal offence?

Been declared bankrupt, insolvent, had a liquidator appointed or been a defendant in any civil court case?

Please provide below information on any insurance claims you have reported in the last 5 years

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss Claim History

DECLARATION AND CONSENT | Please Read Carefully *

I/ We do hereby declare that the above answers and statements are true and that I/ We have withheld no material information regarding this proposal. I/ We agree that this declaration and the answers given above as well as any proposal or declaration or statement made in writing by me/ us or anyone acting on my/ our behalf shall form the basis of the contract between me/ us and the Company. I/ We further agree to accept indemnity subject to the conditions in and endorsed on the Company’s policy.

I/We consent to Trident Insurance Company Ltd; (i) Collecting, using, disclosing and/or processing my/our personal data; and (ii) Transferring my/our personal data to their reinsurers and affiliated companies for the purposes of insurance as permitted by law.

CREDIT INFORMATION | Please Read Carefully *

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