Public Liability | Proposal

Personal Details

Risk Details

Common Details

General Policy Details

Personal Details

Proposer Type

Intermediary

Select Intermediary branch

Binder

ID Type

KRA Pin KRA Pin

First Name

Middle Name

Last Name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

If insured name or other name

Quotation Valid Days

Contact Details

Mobile No.

Telephone No.

Email Address

Postal Address

Postal Office

Town

County

Region

Earth Quake Zone

Physical Address

Which branch do you want to be served from?

Do you have a Fire Industrial from GA Insurance Company Limited?

Period of Insurance

Insurance Start Date

Insurance End Date

Common details

Are the premises plant and machinery in a sound state of repair and will they be so maintained?

Briefly describe the maintenance schedule

Do you use any acids, gases, chemicals, explosives or any radioactive substances in connection with your business?

Substances details 1

Type of Substance

Maximum quantities

Unit

Precaution taken to reduce accident

Will your business activities entail working away from the premises?

Do you have a formally trained, qualified and authorized first aider on the premises during business hours?

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

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

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)

Public Liability Proposal

Period of Insurance

Risk Details

Risk detail 1 Remove

Premises Details

Limit of liability

Cover Extension

please provide the following details:

Common details

Substances details 1

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION AND CONSENT | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *