Accident Insurance - Insurance Hub

GROUP PERSONAL ACCIDENT INSURANCE PROPOSAL FORM
For insurance of financial aid to employees disabled by accident whether at or away from work

First Name

Last Name

Phone no.

Email

Business/ Occupation

Preferred Method of Contact

Phone

Email

other

Residential Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Insurance from

Insurance to

Are all persons to be insured in good state of health and free from physical defect or infirmity?

Please give particulars

Are you or have you ever been insured for these risks.

With which insurers and why was the insurance discontinued

Please indicate the number and brief particulars of accidents which have occurred during the past three years

By submitting this form, I/We hereby warrant and declare the truth of all the above statements and that I/We have not held any material information, and I/We hereby agree to give notice to Alliance & General
Insurance Company Ltd of any variation in My/Our profession, occupation or health of any of
the persons to be insured immediately such information shall come to my/our knowledge.
I/We further agree that this Declaration shall be the basis of the contract between me/us and
Alliance & General Insurance Company Limited and to accept a Policy subject to the terms
exceptions and conditions prescribed by the Company