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SAORSTÁT EIREANN.
2021-09-17/190
WORKMEN'S COMPENSATION ACT, 1934;
EMPLOYERS' LIABILITY ACT, 1880;
FATAL ACCIDENTS ACT, 1846, and
COMMON LAW.
Employers can obtain complete indemnity against their liability for accidents and industrial diseases under all of the above statutes and at Common Law, and against costs, at reasonable rates which will be quoted on receipt of the proposal form within duly completed.
Briefly, the liabilities of an employer under the Workmen's Compensation Act 1934, are:—
(1) In cases of fatal accident:—
(a) If there are total dependants,—from £200 to £600 to dependants.(b) If there are partial dependants,—an agreed sum not exceeding the amount payable under (a).(c) If there are no dependants,—reasonable medical and burial expenses, up to £15.
(2) In cases of permanent disablement by accident:—
A payment for life varying according to the average weekly earnings. The maximum weekly payment is 30/-.
N.B.—In the case of an employee under 21 the payment is liable to be reviewed and assessed on the amount the workman would probably have been earning, but for the accident, with a limit of £1 10/- a week.
(3) In cases of temporary disablement by accident:—
Payments, as under (2), until the disablement is terminated.
(4) Medical Expenses:—
Under Section 73 of the Act, an employer may become liable to pay medical or surgical fees up to £5 in addition to compensation.
NOTES:
(1) "Earnings" means wages (including overtime), board, lodging, commission, and other like emoluments of employment.(2) If disablement lasts less than four weeks, no compensation is payable for the three days; if four weeks or longer, compensation is payable from the date of disablement. Compensation will be paid in all cases from the date of disablement on payment of an additional 5% on the premium for legal liability only.(3) An Employer has no liability under the Act to members of his family dwelling in his house.(4) The Workmen's Compensation Act applies to all manual workers irrespective of the amount of their earnings, and to non-manual workers whose remuneration does not exceed £350 per annum.
Rates will be quoted on application.

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THE LIVERPOOL & LONDON & GLOBE TRANSACTS THE FOLLOWING INSURANCES
FIRE, LIFE, ANNUITIES, MARINE, PROFITS, MOTOR CAR AND CYCLE, EMPLOYERS' LIABILITY, DOMESTIC SERVANTS, PERSONAL ACCIDENT AND ILLNESS, PARTY, FIDELITY GUARANTEE. PLATE GLASS, MONEY AND SECURITIES IN TRANSIT, LIVE STOCK, ENGINE AND BOILER, WIRELESS.
COMPREHENSIVE POLICIES FOR HOUSEHOLDERS.
TOTAL CLAIMS PAID OVER
£179,000,000
ABERDEEN .. .. .150 UNION STREET.
BANGOR .. .. .202 HIGH STREET.
BATH .. .. .21 OLD BOND STREET.
BEDFORD .. .. .DAME ALICE STREET.
BELFAST .. .. .25 WELLINGTON PLACE.
BIRKINGHAM .. .. .1 HAMILTON SQUARE.
BIRKINGHAM, 3 .. .. .55 COLMORE ROW.
BLACKBURN .. .. .17 RICHMOND TERRACE.
BLACKPOOL .. .. .CEDAR SQUARE.
BOLTON .. .. .15 NELSON SQUARE.
BOURNEMOUTH .. .. .49, OLD CHRISTCHURCH ROAD.
BRADFORD .. .. .BRITANNIA HOUSE, 12, LEEDS ROAD.
BRIGHTON .. .. .32A QUEEN'S ROAD.
BRISTOL, 1 .. .. .35 CORN STREET.
BURNLEY .. .. .5 HARGRAVES STREET.
CAMBRIDGE .. .. .SIDNEY HOUSE, SUSSEX STREET.
CAMBRIFF .. .. .11 WINDSOR PLACE.
CARLISLE .. .. .30 LOWTHOR STREET.
CHESTER .. 1 & 2 CATHEDRAL BUILDINGS, ST. WERBURGH ST.
CORK .. .. .60 SOUTH MALL.
CROYDON .. .. .43 HIGH STREET.
DERBY .. .. .19 & 20 CORN STREET.
DONCASTER .. .. .PRUDENTIAL CHAMBERS, SILVER MARKET.
DORCHESTER .. .. .OLD SCHOOL BUILDINGS, SOUTH STREET.
DUBLIN, C. 1 .. .. .1 COLLEGE GREEN.
DUMFRIES .. .. .49 BUCCLEUCH STREET.
DUNDEE .. .. .5 COWGATE.
EDINBURGH, 2 .. .. .107 GEORGE STREET.
EXETER .. .. .8 BEDFORD CIRCUS.
GLASGOW, C. 2 .. .. .123 ST. VINCENT STREET.
GLOUCESTER .. .. .SOUTHGATE STREET.
GREAT GREENSBY .. .. .104 CLEMETHORE ROAD.
GREENOCK .. .. .10 RAWSON STREET.
HALIFAX .. .. .14 HAMILTON STREET.
HAWICK .. .. .25 NORTH BRIDGE STREET.
HEREFORD .. .. .138 WIDEMARSH STREET.
HUDDERSFIELD .. .. .13 STATION STREET.
HULL .. .. .29 SILVER STREET.
IPSWICH .. .. .11 BUTTER MARKET.
LEEDS, 1 .. .. .48 ALBION STREET.
LEICESTER .. .. .TOWN HALL SQUARE.
LINCOLN .. .. .1 CORNHILL.
LIVERPOOL, 2 .. .. .Head Office .. .. .
Do. City Branch .. .. .1 Dale Street.
Do. .. .. .3 COTTON EXCHANGE BUILDINGS.
LONDON (Chief Office) .. .. .1 Cornhill, E.C. 3.
Do. City Branch .. .. .1 WHITEHALL, S.W. 1.
Do. Branches .. .. .2 & 3 FEN COURT, FENCHURCH STREET, E.C. 3.
3 GREAT EASTERN RD., STRATFORD, E. 15.
MAINSTONE .. .. .18 HIGH STREET.
MANSFIELD .. .. .1 ALBERT SQUARE.
MIDDLESBROOK .. .. .55 & 57 LEEMING STREET.
NEWCASTLE UPON TYNE, 1 .. .. .81 HIGH STREET.
NEWPORT, Mon. .. .. .AROADE CHAMBERS, MARKET SQUARE.
NORTHAMPTON .. .. .29 BRIDGESTON GATE.
OLDHAM .. .. .125 UNION STREET.
PETERBOROUGH .. .. .1 CAUSEWAY CHAMBERS, LONG CAUSEWAY.
PLYMOUTH .. .. .34 & 35 BEDFORD STREET.
PORTSMOUTH .. .. .GLOBE CHAMBERS, VICTORIA HALL.
PRESTON .. .. .3 GUILDHALL STREET.
READING .. .. .GLOBE BUILDINGS, 38 FRIAR STREET.
SALISBURY .. .. .QUEEN STREET.
SCARBOROUGH .. .. .BAR CHAMBERS, 2 WESTBOROUGH.
SHERFFIELD, 1 .. .. .PARADE CHAMBERS, EAST PARADE.
SHIREWSBURY .. .. .19 HIGH STREET.
SLOUGH .. .. .48 HIGH STREET.
SOUTHAMPTON .. .. .95 ABOVE BAR STREET.
SOUTHPORT .. .. .33 HOGHTON STREET.
STOKE-ON-TRENT .. .. .KING'S CHAMBERS, KINGSWAY.
SWANSEA .. .. .7 CASTLE BUILDINGS.
TAUNTON .. .. .3 MARKET GATE.
TAURINGTON .. .. .PRUDENTIAL CHAMBERS, LICHFIELD ST.
WOLVERHAMPTON .. .. .10 EGERTON STREET.
WREXHAM .. .. .
EMPLOYERS' INDEMNITY PROPOSAL FORM.
NON-INDUSTRIAL,
MANUFACTURING AND
INDUSTRIAL RISKS.
"KNOWN ROUND THE WORLD"
THE LIVERPOOL AND LONDON AND GLOBE INSURANCE CO. LTD.
HEAD OFFICE LONDON
1, Dale Street Chief Office
LIVERPOOL I CORNHILL
FIRE
LIFE
ACCIDENT
MARINE
O.7250/34

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Branch
Agency
Policy No. W
Order No
THE LIVERPOOL & LONDON & GLOBE INSURANCE CO. LTD.
(INCORPORATED IN ENGLAND)
SAORSTÁT EIREANN — PROPOSAL FOR INSURANCE
AGAINST LIABILITY UNDER THE WORKMEN'S COMPENSATION ACT, 1934; EMPLOYERS' LIABILITY ACT, 1880; FATAL ACCIDENTS ACT, 1846; AND AT COMMON LAW.
Indemnity under any silicosis scheme that may be introduced by virtue of section 79 of the Workmen's Compensation Act, 1934, is not included.
SCHEDULE—ALL PERSONS EMPLOYED MUST BE INCLUDED.
Classification No.
OCCUPATION.
Approximate Number of Employees in each class.
Estimated Annual Cash Wages.
Value of Board, Lodgings and other Allowances (See note *)
Total of Cash Wages and Allowances
Rate %
Premium.
£
%
£
%
.....
Clerical Staff ...
...
...
...
...
...
...
.....
Commercial Travellers ...
...
...
...
...
...
...
.....
Shop Assistants ...
...
...
...
...
...
...
.....
Shop and Workroom Apprentices and/or Learners (no delivery)
...
...
...
...
...
...
*Errand Boys, Apprentices and/or Learners (delivery by hand or handcart)
...
...
...
...
...
...
Do. do. (delivery otherwise)
...
...
...
...
...
...
* Wages to be assessed at not less than £40 each per annum.
...
...
...
...
...
...
Domestic Servants (Minimum Wages Assessment, £50 each)
...
...
...
...
...
...
.....
Caretakers and/or Cleaners (Minimum Wages Assessment, £25each)
...
...
...
...
...
...
.....
Drivers and Vannen ...
...
...
...
...
...
...
.....
Employees engaged with wood-working machinery, including machinists and machinists' labourers ...
...
...
...
...
...
...
.....
Employees engaged with machinery other than wood-working machinery, including machinists and machinists' labourers...
...
...
...
...
...
...
.....
Apprentices (other than above mentioned) and Articled Pupils (whether indentured or not)
...
...
...
...
...
...
.....
(Minimum Assessment £60 each per annum)
...
...
...
...
...
...
.....
All other Employees (please describe fully) ...
...
...
...
...
...
...
.....
Pearsons
...
...
...
...
...
...
.....
...
...
...
...
...
...
Sub-Contracts £
TOTAL (a) £
Do you desire to insure your liability under the Workmen's Compensation Act to the workmen of Sub-Contractors?
If so, state nature of work sub-let and the estimated amount of Contracts.
TOTAL (a)

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(See (4) overleaf) Additional Premium 25% of (a)
(b) £
Do you desire compensation to commence from the first day of disablement where liability for the first three days does not exist? Additional Premium 5% of (a)
* The actual value of the board and lodging, but not less than £25 per annum in respect of each person boarded and lodged, must be added to the wages, or if boarded only or housed only, not less than £12 tos. each.
(c) £
1. (a) Are all of your Employees included in the above Schedule? .. .. (a) (b)
(b) If not, please state particulars of those excluded, and the reason therefor.
2. Do you desire to insure special benefits to any Relatives for whom there is no legal liability under the Acts? If so, state name, relationship and wages. (See Note No. 3 overleaf) .. .. .
3. (a) Have you any circular saws or other machinery driven by steam, gas, water, electricity, or other mechanical power? If so, give full particulars .. .. .
(a) (b)
(b) Are your machinery, plant and ways properly fenced and guarded, and otherwise in good order and condition? .. .. .
4. (a) State which Abstract, if any, of the Factory Act (i.e., Textile, Non-Textile, Laundry Factory, Laundry Workshop, Print Works, Bleaching and Dyeing Works, or Workshop Abstract) is posted in your Works .. .. (a) (b)
(b) If the present insurance applies to more than one Factory, please state (i) the address of each and (ii) which Abstract of the Factory Act is posted in each
(a) (b) (i) (ii)
NOTE:—This information is required for the purpose of making the returns to the Ministry of Industry and Commerce on your behalf under Section 74 of the Workmen's Compensation Act, 1934.
5. State what acids, gases, chemicals or explosives will be used, and to what extent? .. .. .
6. If any Employees are occasionally engaged outside your works state nature of work .. .. .
7. Are your boilers insured against explosion? If so, with whom? .. .. .
8. (a) Are you at present insured, or have you ever proposed for an Insurance in respect of your liability to your Employees? .. .. .
(b) Has any such Proposal or Renewal of your Insurance ever been declined or (c) withdraw? .. .. .
(d) Has any increased rate been required? .. .. .
Number.
Compensation paid to date.
Fatal.
Number.
Number.
Temporary Disablement only.
£
Claims still unsettled.
£
Claims still unsettled.
£
Claims still unsettled.
£
Claims still unsettled.
Number.
Estimated further cost.
Number.
Estimated further cost.
Number.
Estimated further cost.
Number.
Estimated further cost.
Number.
Estimated further cost.
9. Give particulars of accidents to your employees and diseases incidental to their occupation during the past three years .. ..
19 .. .. .
19 .. .. .
19 .. .. .
19 .. .. .
19 .. .. .
19 .. .. .
19 .. .. .
19 .. .. .
19 .. .. .
19 .. .. .
I/We desire to effect an Insurance in terms of the Policy to be issued by the Company against my/our Statutory and Common Law Liability, as above mentioned, and I/we agree to render at the end of each period of insurance, a statement in the form required by you of all wages actually paid, and to pay premium on the wages paid in excess of the amount estimated above, and hereby declare that all the above statements and particulars, which I/we have read over and checked, are true, that I/we have not suppressed, misrepresented or misstated any material fact, that I/we have fairly estimated my/our total wages and salaries expenditure, and I/we agree that this Declaration shall be the basis of the contract between me/us and The Liverpool & London & Globe Insurance Co. Ltd.
Date..... 193
Signature of Proposer
From..... to.....
C.I. PROPL. EXAM. PREM. CH'KD. H.O. ENDTS.
The liability of the Company does not commence until the acceptance of the proposal has been intimated by the Company. or official Cover Note issued.