::.Welcome to Goldlink Insurance.::

We Have added the following new products:
  *School Safety policy.
  *Travel & Tours Insurance.
* Hospitality Plus Insurance.
  *A re-branded auto Insurance
more

PERSONAL ACCIDENT INSURANCE :::

PERSONAL ACCIDENT INSURANCE PROPOSAL FORM

IMPORTANT NOTICE: Kindly complete this form carefully and fully. Failure to disclose all facts likely to influence the acceptance and assessment of this proposal could affect settlement of claims or invalidate your policy. If you are aware of any fact likely to influence the proposal kindly disclose them in the space provided at the end of this proposal. If any answer has been written by any person(s) other than the insured, such person(s) shall for that purpose be regarded as the agent(s) of the Proposer and not the agent(s) of the insurer.

PERSONAL DETAILS

Full Name of Proposer

Residential Address1

Residential Address2

Telephone No.

Business Address 1

Business Address 2

Date of Birth

Age Next Birthday

Nationality

Height

Insurance Required from

Metres weight

OCCUPATIONAL DETAILS

1. Describe fully your business, trade, occupation and nature of work including part-time business, trade and work.

2. Does your job require you to travel regularly? YES NO

If YES, tick mode of travel: Road Air Rail Water

3. Are you aware of any notable risks of accident particularly associated with your job? YES NO

MEDICAL HISTORY

Please answer Yes or No, and give details where applicable

1. Have you any physical defect, infirmity or any defect of your sight or hearing or other senses and faculties? YES NO

2. Have you ever suffered from:
(i)	Clinical depression or anxiety or any nervous or mental condition, fainting episode, blackout fit or paralysis of any kind? YES NO If YES, give Dates and Details
(ii)	High blood pressure, any heart condition, haemorrhoids, varicose veins or other circulatory disorder, diabetes or rheumatic fever? YES NO If YES, give Dates and Details
(iii)	A slipped disc or other spinal disorder hernia or rheumatic or arthritic condition? YES NO If YES, give Dates and Details
(iv)	Any respiratory, urinary or allergic condition or any disorder of the digestive system? YES NO If YES, give Dates and Details
(v)	Any condition or injury that has disabled you for a period of more than 14 days in the last 3 years? YES NO If YES, give Dates and Details
3.	Have you ever received counselling or any medical advice, test or treatment in connection with A.I.D.S or any A.I.D.S related condition? Yes No

RECREATION, PASTIMES AND INSURANCE HISTORY

1. (A) Do you engage in any sport of hazardous pastime? Yes No
Note: The following activities are not covered by the policy: Football, hunting, mountaineering, polo, racing of any kind, winter sports, underwater breathing apparatus, use of woodworking machinery driven by mechanical power.

If you required cover in any of the above activities, indicate the exact requirement:

2. Do you (or intend to) (i) Undertake more than 20 air flights per annum or fly other than as a fare-paying passenger? Yes No If YES, give Dates and Details (ii)Travel extensively or reside temporarily outside Nigeria or visit countries in a state of war or civil unrest? Yes No If YES, give Dates and Details 3. Are you now insured or proposing to insure against Accident or Sickness? Yes No If YES, give Dates and Details 4. Has any insurer, in relation to life, Accident or Sickness insurance ever. (i) decline your Proposal? Yes No If YES, give Dates and Details (ii) Cancelled or refused to renew your Policy? Yes No If YES, give Dates and Details (iii) Had any special condition been imposed on your Policy? Yes No If YES, give Dates and Details

COVER REQUIRED
For what amount do you wish to insure:
A. Death
B. Permanent Disablement
C. Temporary Disablement (per week)
D. Medical Expenses (Limit per Accident)
Tick Scale of Benefits Required: Scale 1 Scale 2
Are there any additional facts/information likely to affect the proposed insurance which should be disclosed to the underwriters? If yes, give details

DECLARATION: I declare that to the best of my knowledge and belief, the information supplied in this proposal form is true and complete. I understand that the cover is not effective until acceptance of this proposal is confirmed.
IMPORTANT NOTICE:
Keep a record of all information supplied to us (including copies of letters) as part of this proposal. - A copy of the completed proposal form will be supplied on request. - A copy of the policy form is available on request for verification prior to completion of the contract. - Notice is to be given immediately to the company of any incidence or occurrence which may give rise to a claim under the policy. - Immediate notice may be given to the Company of any change in occupation or in sports, pastimes or other activities which you regularly pursue if such change involves increased personal hazard.

SCHEDULE OF COMPENSATION FOR PERMANENT DISABLEMENT
SCALE I
Total loss of sight in one or both eyes or total less of one of more limbs	100%
Other Permanent Total Disablement	100%
SCALE II
Total loss of sight in one or both eyes	100%
Total loss of one or more limbs	100%
Other Permanent Total Disablement	100%
Loss of four fingers and thumb of one hand	50%
Loss of four fingers of one hand	40%
Whole thumb	25%
Whole index finger	10%
Whole middle finger	6%
Whole ring finger	5%
Whole little finger	4%
Loss of lens of one eye	50%
Loss of toe on one foot	15%
Loss of hearing - both ears	75%
One ear	15%

Note: * Correspondingly Smaller sums are paid for lesser injuries under Scale II * The aggregate of all percentage in respect of any one accident shall not exceed 100% Definitions: Loss of limbs includes total and irrecoverable loss of one hand or leg. Permanent means lasting 12 consecutive months at the end of that time being without hope of improvement Disablement relates to insured persons occupation. BENEFITS OBTAINABLE UNDER OUR PERSONAL ACCIDENT POLICY (A) Death (within twelve months of an accident) (B) Permanent Disablement (see schedule attached) (c) Temporary Total Disablement (up to 104 weeks) (D) Medical, Surgical and Hospital Expenses (incurred in connection with an accident whether disablement benefit is payable or not). PREMIUM RATES: Premium rates will be quoted on receipt of completed proposal form. SPECIAL ATTRACTION: * Medical Examination is not required * Automatic Travel Cover available for insured who undertakes any travel by land, sea or air (except such is undertaken as a Pilot or a member of the crew) Death, or Permanent Disablement Benefit is payable in addition to any amount already paid or accrued as weekly benefits or medical expenses. NOTE: AGE - LIMIT - 16 to 65 YEARS PRINCIPAL EXCLUSIONS AND CONDITIONS*: The Principal exclusions are as follows: (1) Disease, natural causes, surgical treatment (unless following an insured accident) suicide, attempted suicide, intentional self-injury, deliberate exposure to exceptional danger (except in attempt to save hum life) and the insured person's own criminal act. (2) Riding or driving in any kind of race, operational duties as a member of the armed forces, the mountaineering and rock climbing normally requiring the use of ropes or guides. (3) War, invasion and civil war, invasion of foreigner, riot, commotion, revolution, insurrection or military or usurped power (4) Aviation except when travelling as a passenger. The Personal Accident is subject to certain conditions and exclusions the principal ones of which are listed above. A standard wording is available from the company on request.

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