AUREOL INSURANCE COMPANY LIMITED
INCORPORATED IN SIERRA LEONE
KISSY HOUSE, 54 SIAKA STEVENS STREET, FREETOWN
Tel : +232 22 223435/+232 22 223441/+232 22 225290
Fax : +232 22 229336
Mobile : +23278175175/+23233175175/+23288175175
email : info@aureolinsurance.com
website : www.aureolinsurance.com
BRANCH OFFICE:
13 Tikonko Road
Bo
Tel: +232 32-320108
Mobile: +232(79)175175
PROPOSAL FOR PERSONAL ACCIDENT (Selected Benefits) INSURANCE
(It is important that a complete answer be given to every question including the date of each injury, disease or illness)
NAME OF PROPOSER IN FULL…………………………………………………………………………………………………….
PROFESSION OR OCCUPATION………………………………………………………………………………………………....
ADDRESS…………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………..
TEL. NO…………………………………FAX………………………………….EMAIL……………………………………………
NAME IN WHICH THE POLICY IS TO BE ISSUED…………………………………………………………………………….….
………………………………………………………………………………………………………………………………………..
TERM OF INSURANCE: FROM…………………….………..20……….. . ..TO…….…………………....20………………...
1. State (I) Date of Birth…………………………….. (ii) Height………………………… …. (iii) Weight……………………………….
2. Have you any physical or other defect or weakness of any kind to
the best of your knowledge and belief?
If so, give full details.
3. What injuries, diseases or illnesses have you had?
(Give details and duration in each case.)
4. Has any Company or Insurer in respect of Life, Injury, Illness or
Disease insurance declined or required special terms to insure you?
5. Have you any other Personal Accident Insurance?
If so, give details.
6. Do you engage in any of the activities normally excluded from this
insurance (see below), or any other activity involving additional risk
of accident? Give full details if cover against such risks is required.
7. (a) To what extent will you travel by air?
(b) Do you use an automobile
(I) for traveling to or from your place of business
(ii) in the course of your business,

8. Enter amounts of insurance required in Sections selected (See details overleaf)
FOR OFFICE USE ONLY
Compensation Annual Premium Extra Premium
Section A ………………………………… ………………………. for………………….
Section B …………………………………. ………………………. ……………………...
Section C …………………………………. ………………………. ……………………...
Section D …………………………………. per week ………………………. ……………………...
Section E …………………………………. Per week ……………………….
Section F ………………………………….
I desire to effect with the Company an insurance in the terms of the Policy used for this class of business and I warrant that the above statements and particulars are correct and complete. I agree that this proposal shall be the basis of the contract between me and the Company.
Date……………………………………… ……………… Proposer’s Signature…………………………………………
This insurance will not be in force until the proposal has been accepted by the Company.
The Policy excludes winter sports, football, polo, hunting, mountaineering, motor-cycling, racing of any kind other than on foot, or riot and civil commotion. These generally may be covered for an additional premium.
War and kindred risks and suicide cannot be covered.
.

A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

PERSONAL ACCIDENT INSURANCE
THE “SELECTED BENEFIT” POLICY
INSURANCE AGAINST ACCIDENT DEATH OR INJURY
BENEFITS
Death .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Total and Permanent loss of ——
(1) all sight in both eyes .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
(2) both hands or feet or one hand and one foot .. .. .. .. .. .. .. .. .. .. ..
(3) all sight in one eye and one hand or foot .. .. .. .. .. .. .. .. .. .. .. ..
(4) all sight in one eye .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
(5) one hand or foot .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Other Permanent disablement as specified below .. .. .. .. .. .. .. .. .. .. .. ..
Weekly compensation for Temporary Total Disablement .. .. .. .. .. .. .. .. .. .. ..
Weekly compensation for Temporary Partial Disablement.. .. .. .. .. .. .. .. .. .. ..
Medical Surgical Hospital Nursing Home and Nursing fees or charges .. .. .. .. .. .. .. .. ..
For Sections A to E inclusive, larger or smaller compensation may be insured at proportionate premiums except that——
Section c may not be insured for more than Section B
Section E may not be insured without Section D (maximum under both Sections combined 100 weeks)
nor for more than 40% of Section D
Section E may not be insured without Section D (maximum under both Sections combined 100 weeks)
nor for more than 40% of Section D
Section F may not be insured alone.
Percentage of
OTHER PERMANENT DISABLEMENT (Benefit C) Compensation
Total and permanent disablement from following any employment or occupation .. .. .. .. 100%
Total and permanent loss of hearing or speech .. .. .. .. .. .. .. .. .. 50%
Total and permanent loss of hearing in one ear .. .. .. .. .. .. .. .. .. 15%
Total and permanent loss of arm from shoulder … .. .. .. .. .. .. .. .. 75%
Total and permanent loss of forearm .. .. .. .. .. .. .. .. .. .. 65%
Total and permanent loss of thigh .. .. .. .. .. .. .. .. .. .. 75%
Total and permanent loss of leg at or below knee .. .. .. .. .. .. .. .. .. 65%
Total and permanent loss of thumb (both phalanges) .. .. .. .. .. .. .. .. 25%
Total and permanent loss of thumb (one phalanx) .. .. .. .. .. .. .. .. .. 10%
Total and permanent loss of index finger (three phalanges) .. .. .. .. .. .. .. 10%
Total and permanent loss of index finger (two phalanges) .. .. .. .. .. .. .. .. 8%
Total and permanent loss of index finger (one phalanx) .. .. .. .. .. .. .. .. 4%
Total and permanent loss of finger other than thumb or index finger .. .. .. .. .. .. 5%
Total and permanent loss of great toe .. .. .. .. .. .. .. .. .. .. 5%
Total and permanent loss of any other toe .. .. .. .. .. .. .. .. .. .. 1%
“Total and permanent loss” includes total and permanent loss of use.
In addition compensation is paid for any permanent partial disablement (other than loss of sense of taste or smell) not
specified above, the proportion being assessed by the Company after consulting its Medical Advisers without taking
into consideration the Insured’s occupation.
The maximum compensation under this Section is 100%.
A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

NOTE: THE COMPANY RESERVES THE RIGHT TO DECLINE ANY PROPOSAL.