Titan Insurance Advisors | Insurance Solutions in the Bahamas

Applicant Details

Applicant Name *

Address

Telephone

Email *

Business Name

Years in Business

Nature of Business

Business Type

Past Insurance History

Previous Insurer

Policy Number

Expiry Date

Current Premium

Have you ever been declined insurance?

YesNo

Have you had any special terms imposed?

YesNo

Have you implemented any risk improvements?

YesNo

Employee Details

Total Number of Employees *

Full-Time Employees

Part-Time Employees

Contract Employees

Seasonal Employees

Work Type & Location

Total Wages by Employee Category

Manual Workers (Number)

Annual Wages

Clerical Workers (Number)

Annual Wages

Technical Staff (Number)

Annual Wages

Management Staff (Number)

Annual Wages

Other Staff (Number)

Annual Wages

Total Annual Wages (All Employees) *

Labor Law Compliance & Safety

Machinery & Equipment

Hazardous Materials & Work

Safety Measures

Claims History (Past 3 Years)

Provide details of all workplace injury claims for the past three years

Year 1

Fatal Claims (Number)

Amount ($)

Permanent Disablement (Number)

Amount ($)

Temporary Disablement (Number)

Amount ($)

Year 2

Fatal Claims (Number)

Amount ($)

Permanent Disablement (Number)

Amount ($)

Temporary Disablement (Number)

Amount ($)

Year 3

Fatal Claims (Number)

Amount ($)

Permanent Disablement (Number)

Amount ($)

Temporary Disablement (Number)

Amount ($)

Coverage Required

Limit of Indemnity Per Employee

Aggregate Limit (Optional)

Required Documents

Employee Documents (Optional)

Employee roster, payroll records, job descriptions

Upload files

Safety Documents (Optional)

Safety program, training records, inspection reports

Upload files

Additional Documents (Optional)

Upload files

Declaration & Signature

I/WE declare that the above statements are true and complete and that no material facts have been withheld. I/WE agree that this proposal shall form the basis of the contract with NAGICO Insurance (Bahamas) Limited.

Signature *

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Employers' Liability Insurance Application

Applicant Details

Past Insurance History

Employee Details

Work Type & Location

Total Wages by Employee Category

Labor Law Compliance & Safety

Machinery & Equipment

Hazardous Materials & Work

Safety Measures

Claims History (Past 3 Years)

Coverage Required

Required Documents

Declaration & Signature