APPLICATION FOR WORKMEN'S COMPENSATION      Plan features All information entered is strictly kept confidential

Proposer's Name:
Address:
Trade or occupation:
Place or places of employment:
Title of contract (if any):
Period of insurance (dd/mm/yy):
Occupation/Number/Estimated total wages including housing & food of employees:	Occupation No. of Employees Est. Total Wages Supervisors 3 RM800.00 x 12 mths x 3 Gen workers 25 RM600.00 x 12 mths x 25 others
If sub-contractors' workmen are included in this insurance, please state sub-contractors' names & addresses:	Sub-contractor's Name Address 1) 2) 3)
Particulars of work:
Does the above schedule include all persons in your employ?	Yes       No
Any plant or machinery used?	Yes       No
Is your plant or machinery cerificated by Government authority?	Yes       No
Has any insurer refuse to grant you cover?	Yes       No
Any use of explosives?	Yes       No
Any claim for past 3 years?	Yes       No
Person to contact: Contact tel. number: Email address:
Please check to see that your form is duly completed before you submit.  Thanks.
If you have any query, please use our  Enquiry  form,  E-mail  us  or call  012-5158027