Employer’s Liability Proposal Form Step 1 of 4 25% Particulars of Proposing EmployerName* Employee Registration Number* Postal Address*Email* Telephone* Type of Business* Full description of business transactedPlace of Business & Date of CommencementPresent Insurer Period of insuranceFrom Time* From* DD slash MM slash YYYY To:* DD slash MM slash YYYY LIMITS OF INDEMNITYSpecify below the Limits of Indemnity for which you wish to be covered:Limit of Indemnity for every Employee (Minimum amount in accordance with the provisions of the Law EUR160.000):Select Amount*SelectEURO160.000OtherIf Other Limit of Indemnity for every Event or series of Events (Minimum amount in accordance with the provisions of the Law EUR3.415.000):Select Amount*SelectEURO3415.000OtherIf Other Aggregate Limit of Indemnity for any Period of Insurance (Minimum amount in accordance with the provisions of the Law EUR5.125.000)Select Amount*SelectEURO5125.000OtherIf Other Insurance RecordDo you have now or ever had in the past submitted a proposal in respect of Employers’ Liability Insurance If yes, please state the name of the Insurance Company In relation to the insurance of your employees, has any Insurance Company at any time:- declined you proposal? refused to renew your policy? cancelled your policy? required an increased premium or imposed special conditions? If any of the above was yes please give details Managerial Employees who do not engage in manual labourPlease give details in relation to ALL employees, including their estimated "Gross Earnings" for the period of Insurance. The term "Gross Earnings"shall mean the total wages, salaries, overtime payments, commissions, bonuses, service charges, tips and other payments, without any deduction in respect of Social Insurance, Income Tax, Medical or Provident Fund or other amounts deducted by agreement with the employee(s) or otherwiseNumber of employees Annual gross earnings * Clerical Employees who do not engage in manual labourNumber of employees Annual gross earnings Commercial TravelersNumber of employees Annual gross earnings Other traveling employeesSpecify nature of duties Number of employees Annual gross earnings Salesmen/SaleswomenNumber of employees Annual gross earnings Machine OperatorsNumber of employees Annual gross earnings Mechanics Not Traveling/TravelingNumber of employees Annual gross earnings Other employees engages in manual dutiesSpecify nature of duties Number of employees Annual gross earnings LabourersNumber of employees Annual gross earnings Other (Specify)Specify nature of duties Number of employees Annual gross earnings CLAIMS RECORD State the number of Accidents and Occupational Diseases suffered by your Employees during the last three yearsYear 1Amount paid (In the form of Gross Earnings EUR) Accidents/Diseases (Number of Accidents and Occupational Diseases) CLAIMS SETTLED (Number of claims) CLAIMS SETTLED (Amount Paid) CLAIMS OUTSTANDING (Number of claims) CLAIMS OUTSTANDING (Estimated Cost EUR) Year 2Amount paid (In the form of Gross Earnings EUR) Accidents/Diseases (Number of Accidents and Occupational Diseases) CLAIMS SETTLED (Number of claims) CLAIMS SETTLED (Amount Paid) CLAIMS OUTSTANDING (Number of claims) CLAIMS OUTSTANDING (Estimated Cost EUR) Year 3Amount paid (In the form of Gross Earnings EUR) Accidents/Diseases (Number of Accidents and Occupational Diseases) CLAIMS SETTLED (Number of claims) CLAIMS SETTLED (Amount Paid) CLAIMS OUTSTANDING (Number of claims) CLAIMS OUTSTANDING (Estimated Cost EUR) Particulars in relation to the Proposer's Business1. Give full particulars of Woodworking machinery driven by mechanical power Give full particulars of Other machinery driven by mechanical power 2 Are your ways, works, machinery and plant and business premises properly fenced and guarded and generally in good order and condition? 3 Are your premises in a good state of repair? 4 Do you have any boilers, steam containers and other pressurized vessels, lifts, hoists and cranes? 5 Do you handle or used radio isotopes, radioactive substances or other sources of ionizing radiations? 6 Do you use or keep stored in your business premises any acids, gases, chemicals or explosives or any other dangerous substances? 7 Do you manufacture, dress, handle or used asbestos or silica or any material containing asbestos or silica? 8 Do you keep a foundry? 9 Have you, during the last three years, been accused or convicted, or has a repremand or recommendation been made to you, in relation to any violation or any law or regulation in connection with the safety of your employees? 10 Have you complied with all your obligations emanating from the Laws and Regulations governing the operation or the maintenance of you premises and your machinery and, generally, the safety and health of your employees? 11 Do you carry on any business abroad? In the event that your company carries out business abroad: (a) Name the countries in which business is carried out & (b) Are permanent residents of Cyprus occupied in the business carried out in the above countries? If yes, please specify their names and their type of work Details on AboveFor Data Protection Company Policy Click Here. * I have read the Data Protection Company Policy posted on this website I herewith provide Royal Insurance Company Ltd (and any successors and assignees thereof), my express and unconditional consent regarding the processing and creation of data records in electronic and physical form, of all my relevant personal data, that may include sensitive data which I have declared and submitted