Lions/ LDI/ 00/00/00/001
LEGAL EXPENSE INSURANCE PROPOSAL FORM
LEGAL EXPENSES COVERED:
For both civil and criminal proceedings the sums include; Policy holder’s Lawyer’s fees, Court fees required for filing court documents, Witness
attendance costs, and Legal fees necessary to apply for bail (Refer to the full Policy Document for more benefits)
PROPOSER DETAILS:
NAMED:
_____________ ______________________________________________
OCCUPATION:
________________________________________________
MARITAL STATUS:
________________________________________________
NATIONALITY:
________________________________________________
MALE |
FEMALE (Please tick)
CONTACT/WORK ADDRESS: ________________________________________________
RESIDENTIAL ADDRESS:
________________________________________________
MOBILE:
__________________________________________________
HOME PHONE:
__________________________________________________
EMAIL: _____________________________________________________
LEGAL STATUS:
i.
HAVE YOU SUED OR BEEN SUED IN THE LAST 2 YEARS?
YES | NO
(Please tick)
YES | NO
(Please tick)
If Yes Please Provide Details:
ii.
DO YOU HAVE ANY MATERIAL FACTS TO BE DISCLOSED REGARDING THIS PROPOSAL
If Yes Please Provide Details:
______________________________________________________________________________________________________________________________
POLICY DURATION:
Policy period from ____________________to _____________________ at 12:01 A.M
COVER LIMITS AND PREMIUM PAYMENT OPTIONS
Please tick the preferred limit:
Silver
Maximum Amount Claimable Per
incident/Period of Insurance
Premium Payment Options
Monthly Premium
Annual Premium (10% Discount)
Gold
Platinum
UGX 10,000,000
UGX 20,000,000
UGX 30,000,000
UGX 15,000
UGX 25,000
UGX 35,000
UGX 162,000
UGX 270,000
UGX 378,000
CLASSIFICATION AND PREMIUM
The Premium for this policy shall be paid MONTHLY OR ANNUALLY
a)
At a premium of UGX ____________________________ at inception
b)
UGX____________________________ on 1st of every month there after
THE ABOVE DECLARATIONS, TOGETHER WITH THE STANDARD POLICY TERMS, CONDITIONS, COVERAGE TERMS,
DEFINITIONS AND ANY OTHER ENDORSEMENTS WOULD FORM PART OF THE POLICY TO BE ISSUED.
I/We hereby warrant that the statement made in this Proposal are true and complete and that, to the best of my/our knowledge, nothing material
affectingthe risk has been concealed by me/us. I/We further agree that this Proposal shall be incorporated in the policy and taken as the basis of the
contract between us and Lion Assurance Company Limited
SIGNED ____________________ BY ___________________________________________
(Date)
(Proposed Policy Holder)
SIGNED ____________________ BY ___________________________________________
(Date)
(For Lion Assurance Company)