AUREOL INSURANCE COMPANY LIMITED
INCORPORATED IN SIERRA LEONE
KISSY HOUSE, 54 SIAKA STEVENS STREET, FREETOWN
Mobile : +23278175175/+23233175175/+23288175175
Email : info@aureolinsurance.com
website : www.aureolinsurance.com
BRANCH OFFICE:
17 Tikonko Road
Bo
Mobile: +232(79)175175
PROPOSAL FOR TRAVELLERS’ PERSONAL ACCIDENT INSURANCE
NAME OF PROPOSER IN FULL…………………………………………………………………………………………………………………….
PROFESSION OR OCCUPATION………………………………………………………………………………………………………………….
ADDRESS……………………………………………………………………………………………………………………………………………..
ITINERARY OF JOURNEY…………………………………………………………………………………………………………………………..
TEL. NO………………………………………….FAX………………………………………….EMAIL……………………………………………
TERM OF INSURANCE: FROM…………………….………………..20……….. . ..TO…….………………….…………...20……………
Names in full of Persons to be Relationship to Age Occupation Sum to be insured
Insured (age limits 16—70 years) Proposer against Death
………………………………………………………………………………………………………………………………………………………………………..
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To the best of your knowledge and belief, are the above persons
of sound bodily and mental health and free from infirmity and
physical defect? ……………………………………………………………………………
If not, give details .. .. .. .. .. .. .. .. ……………………………………………………………………………
If the persons to be insured will travel by air
(a) Will they fly only as fare-paying passengers by regular
scheduled airline services? (a) ……………………………………………………………………………
or (b) will they fly in chartered aircraft? (b) ……………………………………………………………………………
If so, state
(I) Name of Charter Company (I) ……………………………………………………………………………
(ii) Type of aircraft (ii) ……………………………………………………………………………

A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

I declare that all the foregoing statements and particulars are true, and I agree that this declaration
shall be the basis of a contract of Insurance to be expressed in the usual terms of the Company’s
Cover Note.
Date:…………………………………………………………………. 20…………
Agency………………………………………………. Proposer’s Signature:………………………………………………….
Name and Address of Beneficiary…………………………………………………………………………………………………………….
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NOTE: THE COMPANY RESERVES THE RIGHT TO DECLINE ANY PROPOSAL.