PROPOSAL FOR WORMEN COMPENSATION INSURANCE
(For risk located in United Arab Emirates)

Name of Proposer
Address
Telephone
Fax
       
Proposer's Trade or Occupation
     
Employee Particulars  
    Numbers Total Salaries Earnings Allowances (Per Year) Overtime
1 Clerical/Adminstrative Staff
2 Sales Staff
3 Industrial Staff including Engineers, Supervisors and Factory Workers

 
Previous Claims History
Sr. Nš Date Type of Claim Amount
            
Proposed Period of Insurance
                
I/We certify that the above information is true to the best of my/our knowledge and belief.
            
Date
Place

 


 


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