Proposal Form You are advised to keep a copy of this Proposal Form for your records. Only the Policy Document provides full details of what is and what is not covered. The full policy can be viewed here.Details of the ProposerFirst Name *Last Name *TitleIf a Company, State Full Legal NamePermanent AddressEmployer's NameEmployer's AddressMailing AddressID Card No / Passport No *Occupation *Nature of BusinessPlace of BusinessMarital StatusContact No (H) *Contact No (W) *Contact No (M) *Fax NoEmail Address *GenderMaleFemaleProposer's ID No / Company's No *VAT No.Upload Photo Identification *Choose FileNo file chosenDelete uploaded fileUpload Proof of Address *Choose FileNo file chosenDelete uploaded fileDate of BirthDaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Country of BirthNationalityPeriod You Require Insurance FromDaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Period You Require Insurance ToDaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Do you have any affiliation to government officials, military officials or any person who provides an important public function/s for the state?YesNoDetails of your PetName of your pet *Type of Pet *DogCatGender *MaleFemaleWeight in lbs *Is Your Pet Microchipped *YesNoMicrochip NumberBirthdate of your pet *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924If exact date is unknown, please indicate to the closest known month and/or yearIs your pet a pure breed? *YesNoPlease specify breed *Pedigree Certificate No *Copy of certificateChoose FileNo file chosenDelete uploaded filePlease specify any known mix of breedsPlease note that our policy may not be eligible for certain breeds of fighting characteristics or those trained to attack. The Veterinarian and/ or the insurance company reserve the right to deny coverage to certain breeds.Name and address of your pet's vet. *Please upload a photo of your petChoose FileNo file chosenDelete uploaded fileAddress where your pet resides (if different from the address of the proposer)Address where your Pet residesInsurance Cover RequirementsInsurance Coverage Type *EssentialPremiumPlease indicate which Plan you would like to purchase. Please refer to our summary of cover for the benefits provided in each Plan Subject to your application being approved and upon premium payment, cover begins immediately from the date of approval. Please note that there is a 30 day minimum waiting period from the commencement date before veterinary treatment cover becomes operative unless otherwise specified in policy.General QuestionsIs your pet neutered or spayed? *YesNoHas your pet ever suffered from any medical conditions in the last 2 years? *YesNoMedical condition detailsHas your pet undertaken any treatment (including surgery) in the last 2 years? *YesNoTreatment or surgery detailsAre your pet’s vaccinations/boosters up to date ? *YesNoIs your pet used for work? *YesNoSuch as but not limited to security, guarding, attack training, track racing or Coursing or any other sportDetails of workHas your pet ever caused damage or injury to any third party, being pet or human? *YesNoDetails of damageAre there other pets in the household? *YesNoList other pets in the householdDoes your pet wear a collar with the name, address and telephone number on it? *YesNoIs your pet currently ill or on any medications *YesNoDetails of illness and/or medication(s)Do you have additional insurance coverage? *YesNoAdditional insurance coveragePropertyAutoLifeAre you satisfied with your insurance coverage? *YesNoMay we contact you about other insurance offerings? *YesNoConsent *I confirm my understanding and acceptance of the above.Special OffersEmailPostPhoneSMSOpt OutWith your consent We would also like to use your details to occasionally provide you with information about Our special offers, competitions, events, products, services, news and tips. Please tick below how you would like to receive this information:DECLARATION I hereby declare that to the best of my knowledge and belief, that whatever, is stated in this Proposal is absolutely true and that I have not concealed, distorted or misrepresented any facts. I also agree that this proposal and declaration shall be absolutely binding upon me, shall form the basis of this Policy between myself and CG United Insurance Ltd. and will be considered as forming part of the Policy to be issued. Non Disclosure Warning: Please note that it is your duty to disclose all facts likely to influence the acceptance of your proposal. Failure to do so will prejudice the settlement of any claim or invalidate your Policy. Please Note: This insurance does not come into force until we have accepted your Proposal. You must inform us of any alteration in the risk in the meantime. IMPORTANT – DO NOT SIGN THIS DECLARATION BEFORE YOU HAVE READ AND UNDERSTOOD IT. If this form is being completed by someone else on Your behalf, please ensure that the details submitted accurately reflect what You have said. By making a request for Insurance with CG United Insurance Ltd., you and any other person/s whom you propose to insure (hereinafter ‘Others’) accept the terms of this statement. You hereby warrant that you have presented this Declaration and the leaflet ‘Information for Policyholders’ to Others. You confirm that you have read, or have had read to you, the contents of the completed Proposal Form and agree that the above statements are, to the best of your knowledge and belief, correct and complete and will form the basis of the contract between you and CG United Insurance Ltd. You are satisfied with the way this proposal has been completed and confirm that if this form has been completed on your behalf by a person (including but not limited to any employee, agent or tied insurance intermediary of CG United Insurance Ltd.), such person, for that purpose, shall be regarded as your agent and not the agent of CG United Insurance Ltd. You agree to read the Policy and be bound by its Conditions. Data and Privacy Protection: CG United Insurance Ltd. are the data controllers, as defined by relevant data protection laws and regulations, of personal data held about you or relating to you and/or to any other person/s whom you insure with (hereinafter ‘Others’). In completing all the forms related to your policies or claims, you confirm your understanding and acceptance of the terms in Data Protection and Privacy Statement. You hereby warrant that you have informed Others why We asked for this information and what We will use it for and have obtained the necessary explicit verbal consent. CG United Insurance Ltd. collects and processes information about you and Others for purposes which include preparing requested quotations, underwriting and administering the insurance proposal and policy, carrying out its contractual obligations including handling and settling of claims, and preventing or detecting crime (including fraud). CG United Insurance Ltd. may monitor calls to and from customers for training, quality and regulatory purposes. CG United Insurance Ltd. may collect and disclose your and Others’ information from/to other entities in order to conduct Our business including: managing claims, which may require obtaining data including medical information from healthcare providers (including any public or private hospital or clinic) and/or your employers (for company schemes) and which you hereby authorise; administering policies with insurance brokers or other intermediaries appointed by the policyholder; helping Us prevent or detect crime by sharing your information with regulatory and public bodies in Barbados or, if applicable, overseas, including the Police, as well as with other insurance companies, or other agencies or appointed experts to undertake credit reference or fraud searches or investigations; and/or Our third party suppliers or service providers to whom We outsource certain business operations. We will retain data for the period necessary to fulfill the above-mentioned purposes unless a longer retention period is required or permitted by law. You can withdraw your consent to CG United Insurance Ltd. processing your personal information which is processed with your consent, e.g., direct marketing, at any time. You have the right to access your personal data and ask CG United Insurance Ltd. to update or correct the information held or delete such personal data from Our records if it is no longer needed for the purposes indicated above. If you and Others consider that the processing of personal data by CG United Insurance Ltd. is not in compliance with data protection laws and regulations, you and Others may lodge a complaint with Us and/or the relevant authority in charge of data protection laws in Barbados. I confirm my understanding and acceptance of the above.Date *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year2024 ............................................................ SignatureSend Message