Workers Compensation Insurance

Tax status

Period of insurance

at 4 p.m.

Please list all employed members of an employer's family residing in the employer's dwelling. List all directors of the employer and remuneration.

Note: Any such persons not included in this Schedule are not insured.*

I/we acknowledge that the information given is accurate and complete and that I/we have complied with the obligation imposed by law concerning disclosure of information.

I/we agree that this proposal shall, subject to the terms and conditions of the Policy, be the basis of the contract.