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
Tel: +232 32-320108
Mobile: +232(79)175175
PROPOSAL FOR PUBLIC LIABILITY INSURANCE
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……………
1. Schedule of Premises or outside contracts to which the insurance is to apply
Number of Description of Premises (e.g. Office, Shop Freeholder, Leaseholder
Situation of Premises or sites of contracts Employees Building Store, Factory or Showroom or Contracts or Tenant
2. If you do not occupy the whole of the premises state which part you occupy. If you have
tenants or sub-tenants please give particulars.
3. Do you or any of your employees undertake duties away from the premises for the purpose
of your business? If so, give particulars.
4. What are your estimated total annual wages and salaries including remuneration of (a) Own premises
working partners and directors? (b) Work elsewhere
5. What are your estimated total annual payments to sub-contractors?
6. What is your estimated annual turnover?
7. What lifts elevators, escalators, cranes and hoists used in your business are to be included
in the insurance?
NOTE—If any passenger lifts, elevators or escalators are to be included in the insurance the
latest inspection reports in respect of such lifts elevators or escalators must be submitted
with this proposal.
8. State particulars of any machinery used (other than lifts, elevators, escalators, cranes and
hoists).
9. What vehicles (including pedal cycles), vessels or crafts are to be included in the insurance?
NOTE—A separate insurance is necessary for mechanically propelled vehicles or motor-
cycles, mechanically assisted pedal cycles if used on a public road.
10. Are all your premises, machinery, appliances and plant sound and in good repair?
11. Do you handle or use
(a) explosives or chemicals (a)
(b) radio isotopes radioactive substances or other sources of ionising radiations (b)
UPON REQUEST.
A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

A COPY OF THE POLICY IS AVAILABLE UPON REQUEST.

12. Do you require the insurance to indemnify you in respect of:
(a) defective sanitary arrangements? If so, state when drains were last (a)
inspected and if now in good order.
(b) water pollution” If so, give details of any factors likely to cause water (b)
pollution.
13. What claims have been made on you during the last five years?
14. Amount of Indemnity required.
(a) Have you ever proposed for insurance or been insured against the (a)
liability to which this proposal relates? If so state name of Insurer.
(b) Has any Company or Insurer:-
(I) declined to insure you? (b) (I)
(ii) required special terms to insure you? (ii)
(iii) cancelled or refused to renew your insurance? (iii)
16. What other insurances have you with the Company?
I/We desire to effect with the Company an insurance in the terms of the policy used for this class of business and I/We warrant that the above statements and particulars are correct and complete. I/We agree that this proposal shall be the basis of the contract between me/us and the Company.
Date…………………………………………………………………........ Signature of Proposer……………………………………………………………..
NOTE: THE COMPANY RESERVES THE RIGHT TO DECLINE ANY PROPOSAL.