 |
|
|
|
|
Sample High Limit Accident Declaration of Insurance
THE FOLLOWING IS ONLY A SAMPLE
| Owner: |
|
Certificate Number: |
|
|
Contract Number |
| Address: |
|
Premium: |
|
|
ESL Tax: |
|
|
Processing Fee: |
| Insured: |
|
Total: |
|
|
Payment Mode: |
| Employer's Name: |
|
Effective Date: |
| Occupation: |
|
Expiry Date: |
| Beneficiary: |
|
Issue Date: |
| Geographical Location: |
|
Application Date: |
We, Certain Underwriters at Lloyd's, in consideration of the statements made in Your application for this insurance and the timely payment of premiums, agree to insure You against the perils shown in the Schedule of Benefits, subject to the terms and provisions of this certificate, from the effective date to the expiry date. We will, subject to the terms of this certificate, pay the benefits shown in the Schedule of Benefits. This certificate is a legal contract between You and us.
Coverage under this certificate will begin on the effective date at 12:01 AM. Coverage will end on the expiry date at 12:01 AM. All times will be the Local Standard Time at Your home address stated above.
To become effective, this certificate must have been issued, the initial premium must have been paid and there must not have been any material changes in Your health, occupation or income as described on the application for this certificate.
If there have been any material changes in Your health, occupation or income since the date of signing the application for this insurance, this certificate must be immediately returned to us with a written description of such changes for our review and consideration.
We issue this certificate based on Your occupation and duties on the effective date as described on Your application. If You change Your occupation You must give us notice of that change. Unless We agree to continue this certificate, it will end on the date of the change, unless We agree to continue this certificate after the change. We may charge an additional premium if the new occupation is considered more hazardous than the previous occupation.
We reserve the right to not pay benefits, otherwise payable, if You change Your occupation and do not obtain our agreement to insure You in Your new occupation. In the event that We refuse to agree to insure You in Your new occupation We will return any unearned premiums from the date of change on a pro-rata basis. |
THE ABOVE IS ONLY A SAMPLE |
|
|
|
|
Last updated on: 10/14/2012
|
|
|
|
|
|
