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DATA REQUEST FORM– WORK INJURIES BENEFITS ACT (WIBA)

DETAILS OF PROPOSER

 
Name: Postal address:
Tel.No. Email address:
Occupation: Age 18 – 65 Yrs:

Any physical infirmity

 
   

DETAILS COVER

   
Sum insured 1) Death 2) Permanent total disablement 3) Temporary total disablement
Medical expenses Funeral Expenses  
Number of persons covered Life assistant Estimated Annual Wage roll

Accumulation Limit

   

OTHER POLICIES

 
Any other policy insuring this risk?
. If so state insurer and policy number

INSURANCE HISTORY

 

Has any insurer -:

Declined to insure you?
Required special terms to insure you?
Cancelled or declined to renew your insurance?
Increased premium at renewal?

If you answered yes above please give details

CLAIMS HISTORY

 

Have you claimed in the past?

If so give details


DECLARATION

I do hereby declare that the above answers are true and I have not withheld any material information regarding this proposal.

SIGNATURE __________________

DATE: _____/_____/_____

Click to download Data request form –Work Injuries Benefits Act (WIBA)
Data request form –Work Injuries Benefits Act (WIBA)
 
 
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