Insure Your Vehicle
(1) Specific benefits indicate the amount of insurance required for each item
(2) Specific benefits indicate the amount of insurance required for each item
(3) Specific benefits indicate the amount of insurance required for each item
(4) Specific benefits indicate the amount of insurance required for each item
(5) Specific benefits indicate the amount of insurance required for each item
(6) Specific benefits indicate the amount of insurance required for each item
(1) Select the fold or parts of the annual basic salary / pay required insurance under each item
(-) Persons to be insured
(2) Select the fold or parts of the annual basic salary / pay required insurance under each item
(3) Select the fold or parts of the annual basic salary / pay required insurance under each item
(4) Select the fold or parts of the annual basic salary / pay required insurance under each item
(5) Select the fold or parts of the annual basic salary / pay required insurance under each item
If the amounts of insurance required for salaries or wages, what is the maximum salary or wage paid to any person?
Indicate the collective maximum amount of insurance required for all persons as a result of a single accident.
Would you like to exclude the first weeks of the provisional total disability versus a deduction in the insurance contribution? If yes, specify the numbers of weeks.
What value do you wish to cover medical expenses for an accident that is not excluded by this document?
If such coverage is not required.
Do you currently carry a personal accident insurance policy? If yes, with any company and for any benefits.
Please give details of any accidents that occurred during the previous three years and caused permanent death or disability of employees.
Has any insurance company refused to request personal accident insurance for groups, refused to continue such insurance or imposed special conditions? If so please give details
I herbey acknowledge / confirm that my answers / answers contained in this application are true and correct to the best of my knowledge / belief.
