Name of Proposer in Full: Correspondence Address Row1:
Correspondence Address Row2: Email Address: Contact No: Fax No:
From: TO: Name of Employer in Full: Business Registration No: Place
of Employment: Description of Employer's Business / Profession:
Year of Established: Nature of Work and No: of Employee(s) Row1: of
Employee(s) Row2: of Employee(s) Row3: of Employee(s) Row4:
Occupation of Employee(s) by Categories Row1: Occupation of
Employee(s) by Categories Row2: Occupation of Employee(s) by
Categories Row3: Occupation of Employee(s) by Categories Row4:
Occupation of Employee(s) by Categories Row5: Occupation of
Employee(s) by Categories Row6: Occupation of Employee(s) by
Categories Row7: Occupation of Employee(s) by Categories Row8:
Occupation of Employee(s) by Categories Row9: No: of Employees
Row1: 0 of Employees Row2: of Employees Row3: of Employees Row4: of
Employees Row5: of Employees Row6: of Employees Row7: of Employees
Row8: of Employees Row9:
Estimated Total Annual Earning Row1: Estimated Total Annual
Earning Row2: Estimated Total Annual Earning Row3: Estimated Total
Annual Earning Row4: Estimated Total Annual Earning Row5: Estimated
Total Annual Earning Row6: Estimated Total Annual Earning Row7:
Estimated Total Annual Earning Row8: Estimated Total Annual Earning
Row9: Total of Employees: 0Total of Estimated Earning: 0Position:
Name: Working / Qualification / Certificate of Employer: Name of
Insurance Company: Date - 1: Name - 1: Position - 1: Check Box23:
OffAccount No: Policy No: Check Box1: OffCheck Box2: OffCheck Box3:
OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7:
OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11:
OffClassificate No Row1: 0Classificate No Row2: Classificate No
Row3: Classificate No Row4: Classificate No Row5: Classificate No
Row6: Classificate No Row7: Classificate No Row8: Classificate No
Row9: Total of Classificate No: 0Warranty Row1: Warranty Row2:
Warranty Row3: Warranty Row4: Warranty Row5: Warranty Row6:
Warranty Row7: Warranty Row8: Warranty Row9: Total of Warranty:
0Premium Row1: Premium Row2: Premium Row3: Premium Row4: Premium
Row5: Premium Row6: Premium Row7: Premium Row8: Premium Row9: Total
of Premium: 0Rate Percent Row1: Rate Percent Row2: Rate Percent
Row3: Rate Percent Row4: Rate Percent Row5: Rate Percent Row6: Rate
Percent Row7: Rate Percent Row8: Rate Percent Row9: Total of Rate
Percent: 0Accident Year Row1: Accident Year Row2: Date of Accident
Row1: Date of Accident Row2: PC-No: of Case Row1: of Case Row2: of
Case Row3: of Case Row4: of Case Row5: of Case Row6:
PC-Amount Row1: PC-Amount Row2: OC-No: of Case Row1: of Case
Row2: of Case Row3: of Case Row4: of Case Row5: of Case Row6:
OC-Amount Row1: OC-Amount Row2: Total No: of Case Row1: 0 of
Case Row2: 0 of Case Row3: 0 of Case Row4: 0 of Case Row5: 0 of
Case Row6: 0
Amount of Year Row1: 0Amount of Year Row2: 0Brief Details of
each Accident Row1: Brief Details of each Accident Row2: Paid Row1:
Paid Row2: Outstanding Row1: Outstanding Row2: Variation Date Row1:
Variation Date Row2: Accident Year Row3: PC-Amount Row3: OC-Amount
Row3: Amount of Year Row3: 0Date of Accident Row3: Paid Row3:
Outstanding Row3: Variation Date Row3: Brief Details of each
Accident Row3: Accident Year Row4: PC-Amount Row4: OC-Amount Row4:
Amount of Year Row4: 0Accident Year Row5: PC-Amount Row5: OC-Amount
Row5: Amount of Year Row5: 0Date of Accident Row4: Paid Row4:
Outstanding Row4: Variation Date Row4: Brief Details of each
Accident Row4: Date of Accident Row5: Paid Row5: Outstanding Row5:
Variation Date Row5: Brief Details of each Accident Row5: Date of
Accident Row6: Paid Row6: Outstanding Row6: Variation Date Row6:
Brief Details of each Accident Row6: Accident Year Row6: PC-Amount
Row6: OC-Amount Row6: Amount of Year Row=6: 0Date: Check Box24:
OffFull Name (Eng: ):
