Workers Compensation Cover form | Makz Insurance

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Workers Compensation Cover Form

MakZ Insurance Brokers Ltd

This insurance provides indemnity under the Workers' Compensation Act (Cap 55:03) and at Common Law. Please provide complete answers to all questions. If space provided is insufficient, please provide information on a separate sheet.

1. Period for which insurance is required: From (dd/mm/yy)

To (dd/mm/yy)

2. Proposer's Details a. Proposer's name in full

b. Proposer's business address (line 1)

b. Proposer's business address (line 2)

c. Proposer's trade or occupation

d. Particulars of work carried out

Description of All Workers(type of job/Occupation)

Estimated Number of workers

Estimated Annual Wages/Salaries/Other Earnings

Description of All Workers

Estimated Number of workers

Estimated Annual Wages/Salaries/Other Earnings

Description of All Workers

Estimated Number of workers

Estimated Annual Wages/Salaries/Other Earnings

Description of All Workers

Estimated Number of workers

Estimated Annual Wages/Salaries/Other Earnings

Description of All Workers

Estimated Number of workers

Estimated Annual Wages/Salaries/Other Earnings

Description of All Workers

Estimated Number of workers

Estimated Annual Wages/Salaries/Other Earnings

4. Does the schedule above include: Permanent workers – number

Permanent workers – annual earnings

b. Temporary or casual labourers – number

b. Temporary or casual labourers – annual earnings

5. a. Do your premises come within the meaning of any law or regulations governing the conduct or maintenance of such premises? (Yes/No)

5. b. If so, name such laws or regulations

5. c. Have you carried out all obligations imposed on you by such laws or regulations? (Yes/No)

If No, furnish details

6. a. Do you have any circular saws or other machinery driven by steam, gas, water, electricity or other mechanical power? (Yes/No)

If Yes, furnish details

(i) Does the machinery have safeguards to prevent accidents to workers? (Yes/No)

(ii) Are workers provided with necessary safety equipment such as gloves, goggles, welding shields etc? (Yes/No)

(iii) Does the supervisor check whether these are used by workers? (Yes/No)

6. b. Are your machinery, plant and ways properly spaced and kept in good working order and condition? (Yes/No)

7. Do you have boilers? (Yes/No)

If Yes, furnish details

8. State what acids, gases, chemicals, dust or explosives will be used and to what extent

9. Do all or some of the workers to be covered under this policy have any other accident insurance? (Yes/No)

If Yes, please give details

Declaration (read-only): I/We warrant that the above statements and particulars are correct and complete. I/We agree that this proposal and declaration shall be the basis of the contract between me/us and the Insurer.

Date

Signature of Insured

Name

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