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 EMPLOYER’S LIABILITY
NAME OF PROPOSER IN FULL…………………………………………………………………………………………………………………….
(If an unlimited company or partnership include full names of all parties)
PROFESSION OR OCCUPATION………………………………………………………………………………………………………………….
ADDRESS……………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………...
TEL. NO………………………………………….FAX………………………………………….EMAIL……………………………………………
NAME IN WHICH THE POLICY IS TO BE ISSUED…………………………………………………………………………….…………………..
………………………………………………………………………………………………………………………………………………………...
TERM OF INSURANCE: FROM…………………….………………..20……….. . ..TO…….………………….…………...20……………
Description of Employees Estimated Number Estimated Annual Wages
Salaries and Other Benefits
1 a) Clerical Staff
b) Supervisory Staff
c) Management Staff
d) Shop Assistant
e) Employees using power-driven woodworking
machinery
f) Employees using other
g) Other Employees
(please describe)
2 a) Do you wish to insure your liability to the workmen of sub-contractors?………………………………………………………………...
b) If so please state:-

A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

Name of Contractor Nature of Work If Contract for Labour and If Contract for Labour and
Sublet Materials state amount of Materials state amount of
Contract Contract
3. Are your premises in a good state of repair?…………………………………………………………………………………………………..
4. a) Do you have: I) Plant and Machinery……………………………………………………………………………………..
ii) Boilers and Steam Containers…………………………………………………………………………..
iii) Lifts, Hoists or Cranes ……………………………………………………………………………………..
b) Are these regularly inspected to comply with statutory requirements?…………………………………………………………
5. Are any of the following used in connection with your business?
I) Chemicals, Gases, Explosives…………………………………………………………………………………………………………….
ii) Polluting substances………………………………………………………………………………………………………………………..
iii) Radioactive substances…………………………………………………………………………………………………………………..
6. a) Have you been previously insured in respect of your liability to your Employees?……………………………………………
If so please state name of Company…………………………………………………………………………………………………..
b) Has any Insurer declined to insure you, cancelled or refused to renew your insurance, required an increased pre- mium or imposed special terms?………………………………………………………………………………………………………..
If yes, please give details…………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………….
7. Please give details of all claims made against you (and all occurrences which may lead to claim in the last three years….
…………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………………..
8. Do you require cover for Medical Expenses in respect of your employees?…………………………………………………………….
If yes, state amount of cover required per employee………………………………………………………………………………………..

9. Please note that you are bound by the conditions of your policy:
a) to keep a proper wages record.
b) to allow the company at all times to inspect such record.
c) to supply within one month of expiry of the Period of Insurance the actual wages, salaries and other cash benefits
paid during that period.
10. I/We agree that this proposal and declaration shall be the basis of the contract between me/us and the Company.
I/We agree to keep a proper Wages Record and to render at the end of each period of insurance a statement in the form required by the Company of all wages actually paid and pay premium on any wages paid in excess of the amount estimated above. I/We declare that the above statements and particulars are true and complete and that I/We have
not withheld any material fact.
Signature of Proposer…………………………………………………………. Date……………………………………………………….
Official Stamp…………………………………………………………………………………………………………………………………..
NOTE: THE COMPANY RESERVES THE RIGHT TO DELINE ANY PROPOSAL.