General Third Party Liability Insurance Proposal Form   Please select the country/city where the form is to be submitted -Select Country- Kuwait Lebenon Saudi Arabia U.A.E 1 General 1. Full name of Proposer 2. Address Telephone No Fax No E-mail 3. Have you ever had an insurance of this nature declined, terminated or subjected to special terms by any insurer? If "YES" please give name and address of the insurer concerned select Yes No 4. Please state: (a) limit of indemnity for any occurrence (Note: The indemnity for any one year may in certain circumstances be limited to the same as that for any one occurrence) (b) Period of insurance required: From To 5. Do you undertake work under agreements which impose on you liability for injury, illness, loss or damage for which you would otherwise not be liable? If "YES" please give details select Yes No 2 Persons Employed Description of Persons Number Estimated Annual Payments. Clerical commercial travellers and managerial employees (including working Directors and Partners) who do not engage in manual labour All other direct employees (including remuneration of working Directors and Partners) Please list occupations. (a) work on your premises (b) work away from your premises 2 Premises 1. Address of the premises to which the insurance apply 2. Nature of work undertaken 3. Do you wish to insure your premises as: (a) Owners only select Yes No (b) Tenants only select Yes No (C) Both Owners and Tenants select Yes No 4. Do you let or sublet any party of the premises If "YES" please give details select Yes No 5. Are the premises in good state of repair, both inside and out select Yes No 6. Give details including the position of : (a) any trapdoors, cellar flaps or other openings in floors, pavements, etc., including pavement lights (b) any outside advertising boards or signs 7. Have the public access to your premises? If "YES" to what extent? select Yes No 4 Work away from Premises 1. Do you wish to insure your liability arising from work carried out away from the permises If "Yes" please complete questions 2-4 below select Yes No 2. Do you undertake any work in connection with (a) aircraft, hovercraft or airports? select Yes No (b)water craft or railway rolling stock? select Yes No 3. Do you undertake demolition as a separate trade or pile driving select Yes No 4. Do you use welding or flame-cutting equipment, blow lamps or blow torches away from your own premises. If "Yes" please give details select Yes No 5 Processes 1. Do you handle or use (a) radioactive substances or other sources of ionising radiations? select Yes No (b) acids, gasses, explosives or dangerous substances? select Yes No 2. Does your trade or business lead to the production of noxious fumes, effluent or poisonous waste? If answer "YES" please give details select Yes No 6 Plant and Machinery   Use this space to list all plant and machinery used by you: Solely on premises Away on premises 1. Is all machinery and equipment in good state of repair? select Yes No 2. Is all machinery and equipment regularly maintained and serviced? select Yes No 3. Is all machinery adequately fenced and guarded? select Yes No 7 Good sold or supplied Complete this section if you wish to insure your liability for injury or damage caused by goods sold or supplied. 1. Please State (a) nature of goods (b) whether you are a manufacture wholesaler or retailer (c) estimated annual turnover - Within Country - Exports If so goods are exported to, which countries? 2. Do you sell or supply an imported goods select Yes No (a) from which countries (b) estimated annual turn over from imports 3. Are any of your products intended for use on aircraft or water craft? If "YES" please give details on space provided for additional information. select Yes No 4. If you supplied food or drink to members of the public, is this supplied in hygienic conditions? select Yes No 8 Claims history Please give details of claims made against you in the last five years. If none, state "NONE" Include a note of accidents for which no claim has yet resulted. Year No. of Accidents Details of Accidents (continue on space provided for additional information if necessary) Amount Paid Amount Still To Be Paid Decleration I/We declare that the answers are true and agree that this Proposal shall be the basis of the Contract between me/us and "Compagnie Libanaise d'Assurances s.a.l." and I/We agree to a Policy in the usual form issued by the Insurance Company for this class of insurance. The liability of the company does not commence until the proposal has been accepted by the Company.   [ To download the form please rightclick the Download button and select "Save target as" and Save.]  Download the Form             Download Acrobat Reader Top