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Employees Compensation Insurance Proposal Form: D D M M Y Y Y Y D D M M Y Y Y Y
Employees Compensation Insurance Proposal Form: D D M M Y Y Y Y D D M M Y Y Y Y
Note: If at any time during the Period of Insurance any Employee of the Insured so declared shall sustain Injury by accident arising out of and in
the course of his employment in the Business, Indemnity shall be under Law(s) opted for, subject to the terms, exceptions and conditions
contained in the Policy wordings or endorsed hereon, upto the Limit of Indemnity against all sums for which the Insured shall be so liable which is
agreed by the Insurer and mentioned on the Policy Schedule.
7. COVERAGE’S REQUIRED
Coverage Scope of coverage Aggregate Limit of Indemnity Coveage Options
[Yes/No]
Employees Subject otherwise, to the Limit: As per
Compensation terms, conditions & Exclusions Employees Compensation Act
of the Policy, the amount of
liability incurred by the
Insured.
Common Law Subject otherwise, to the a) Limit Per Employee for any number of accidents during
terms, conditions & Exclusions Period of Insurance
of the Policy, the amount of Rs.____________________________
liability incurred by the
Insured, but not exceeding: b) Limit Per Accident for any number of Employees
Rs.____________________________
* Wages means the remuneration payable to an Employee by the Insured for the employment in the Business and includes any privilege or benefit
which is capable of being estimated in money other than a travelling allowance or the value of any travelling concession or a contribution paid by
the employer of a employee towards any pension or provident fund or a sum paid to a employee to cover any special expenses en tailed on him by
the nature of his employment;
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OWN EMPLOYEE DETAILS**
Description of Employees Declared Number of Employees Total Declared wages during the Place/Places of Employment
period of insurance.
CONTRACTORS EMPLOYEE DETAILS [if the coverage has been opted for]**
Contractors Name Registered Address Declared Number of Total Declared wages Place/Places of
Employees during the period of Employment
insurance.
State the total wages paid and particulars of accidents to your contractors employees during the past three years.**
Year [Past 3 years from this date] Wages Paid Amount of Loss
9. PAYMENT DETAILS :
Premium paid by Cash/ Cheque No ______________________Date: DD/MM/YY Bank ____________________________________
PAN _____________________________________________________ (if premium payable is above Rs.1 lac (Please attach proof)
PRECI01_Ver_03
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