Employer's Liability Insurance Proposal Form   The Cover An employer is liable at law to pay Compensation to his Employees in the event of his employees suffer death, bodily injury or certain occupational disease arising out of an in the course of such employment. Employer's Liability - Extension The Company provides full and complete indemnity to the Employer in respect of the Employer's liability at law to pay Compensation to his Employees.   Please select the country/city where the form is to be submitted -Select Country- Kuwait Lebenon Saudi Arabia U.A.E 1 Proposer's Name in Full 2 Proposer's Business Address 3 Proposer's Trade or Occupation 4 Telephone No: 5 Fax No: 6 E-mail 4 Particulars of Work. All persons within the scope of the Workmen's Compensation Act, must be included For Office Use Only    Estimated Annual Wages, Salaries and other Earnings.   Description of Employees' Estimated number of Employees Cash Value of food fuel & quarters or other consideration in addition to money earnings Total Rate % Premium Classification No. Clerical Staff   Commercial Travellers Apprentices and Articled pupils   Employees engaged with Woodworking Machinery, including Machinist's Labourers Others viz:   The Total amount of wages, salaries and other earnings paid by me/us to the above mentioned employees during the past twelve months was    4 box5  Do you wish to insure your liability under the Workmen's Compensation Act, to the workmen of sub-contractors? select Yes No (i.e. of 'Contractors" as defined in Act) If so, Please State:       Name of the Contractor Nature of Work Sublet If contract for labour and materials state estimated amount of contract In cases for which the contract is for labour only, state Amount of Contract.             Total Premium :     Claims History Year Annual Wages Paid No. of Accidents Total Compensation Paid Estimated Compensation yet to be paid Total Period of Insurance        from              to Declaration I hereby declare that this proposal shall be basis of a contract between myself/ourselves and "Compagnie Libanaise d' Assurances s.a.l" [ To download the form please rightclick the Download button and select "Save target as" and Save.]  Download the Form           Download Acrobat Reader Top