Policy No………………………………………………….

WORKMENS’ COMPENSATION ORDINANCES CHAP. 377 OF THE REVISED LAWS OF ANTIGUA # 24/1956. AS AMENDED

Name of Proposer in full.........................................................................................................................................................................

Business Address......................................................................................................................................................................................

Proposer’s Trade, Business or Occupation...............................................................................................................................................

Particulars of Work................................................................................................................................................................................

Place/s of Employment...........................................................................................................................................................................

SCHEDULE A

All persons within the scope of Workmen’s Compensation Ordinance # 24/1956 must be included

Estimated Annual Wages Salaries and Other Earnings

Office Use Only

Occupation of Employees

Estimated Number of Employees

Cash

Value of Food, Fuel and Quarters or Other Considerations in Addition to Money earnings

Total

Rate

Per cent

Premium

Classification No

The total amount of wages, salaries and other earnings paid by me/us to the above-mentioned employees during the

past twelve months was $..............................................................................................................

Do you wish to insure your liability under the Workmen’s Compensation Ordinance

# 24/1956 to include the workmen of sub-contractors? (i.e. “Contractors” as defined in the #24/1956 Ordinance).

If so PLEASE STATE:

Names of Contractors

Nature of Work

subject

If contract for labour and

materials state estimated

amount of contract

In cases for which the contract is for labour only state amount of contract

Total

Premium $

SCHEDULES B AND C

Employees NOT within the scope of the Workmen’s Compensation Ordinance CHAP, 377 #24/1956, may be insured

1. To secure benefits as though they were Workmen, as defined in the Ordinances (Schedule B) or

2. To secure indemnity in respect of liability at Common Law only (Schedule C)

(Note – If Insurance is required under either of these Schedules ALL such employees must be included in the Schedule Selected.)

			Estimated Annual Wages Salaries and Other earnings Official Use Only
Description of Employees	Estimated Number of Employees	Cash	Value of Food, Fuel and Quarters or Other Considerations in Addition to Money Earnings	Total	Rate Per cent	Premium $	Classification No
SCHEDULE B Benefits of the Ordinances





SCHEDULE C Common Law Liability only



The total amount of wages, salaries and other earnings paid by me/us to the above-mentioned employees during the past twelve months was Total Premium $

1. Does the SCHEDULE A above include a) All persons in your service? and a) ....................................................................................

b) All your Sub-Contractors b) .................................................................................

2. If the Insurance is to extend to employees not within the scope of the Ordinances (See Schedules B and C) do the

Schedules include all such persons in your service? ...................................................................................

3. Do your premises come within the meaning of any Ordinance or Regulation governing the conduct or maintenance

of such premises? ................................................................................

a) If so, name such Ordinances and Regulations a)............................................................

b) Have you carried out all the obligations imposed on you by such Ordinance and/or

Regulations? b)............................................................

4. a) Have you any circular saws or other machinery driven by steam gas, water, electricity or other mechanical power?

If so, give full particulars a)............................................................

b) Are your machinery, plant and ways properly fenced and guarded and otherwise in good

order and condition? b)............................................................

5. What Boilers have you? ...............................................................

6. State what acids, gases, chemicals or explosives will be used and to what extent ...............................................................

7. State hereunder amount of wages paid and give particulars of number of accidents to your employees incidental to their

occupation during the past three years. ...............................................................

	FATAL		PERMANENT DISABLEMENT		TEMPORARY DISABLEMENT ONLY
YEAR WAGES	NUMBER	COMPENSATION PAID TO DATE	NUMBER	COMPENSATION PAID to DATE	NUMBER	COMPENSATION PAID to DATE
20 $		$		$		$
20 $		$		$		$
20 $		$		$		$
	CLAIMS STILL UNSETTLED		CLAIMS STILL UNSETTLED		CLAIMS STILL UNSETTLED
	NUMBER Estimated further Cost $		NUMBER Estimated further Cost $		NUMBER Estimated further Cost $

8. a) Are you at present insured, or have you proposed for an insurance in respect of your liability to your

Employees? If so please state name of Company a)............................................................

b) Has any such Proposal or Renewal ever been declined or withdrawn? b)............................................................

c) Has an increased rate been required c)............................................................

9. Please state period of Insurance required From........................................................... To...............................................................

I/We the undersigned, desire to effect an insurance as above stated in terms of the Policy to be issued by the Company.

I/We agree to keep a proper Wages Record and to render at the end of each period of insurance a statement in the form required by the Company

of all wages actually paid and to pay premium on any wages paid in excess of the amount estimated above. I/We hereby

declare that all the above statements and particulars which I/we have read over and checked are true, that

I/We have not suppressed, misrepresented or misstated any material fact, that I/We have fairly estimated my/our total wages

and salaries expenditure and I/We agree that this declaration shall be the basis of the contract between me/us and the

ABI Insurance Company limited.

Date........................................................................ 20........... Signature of Proposer............................................................................