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KeyMan Questionnaire

This document contains a questionnaire for assessing keyman insurance. It requests information about the keyman, their role and importance to the company, company financials, succession planning, existing insurance policies, and authorization for the keyman insurance purchase. Specifically, it seeks details on the keyman's name, duties, expertise, compensation, replacement plan, existing policies, and board approval to purchase a new keyman insurance policy for the individual.

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badasserytech
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92 views

KeyMan Questionnaire

This document contains a questionnaire for assessing keyman insurance. It requests information about the keyman, their role and importance to the company, company financials, succession planning, existing insurance policies, and authorization for the keyman insurance purchase. Specifically, it seeks details on the keyman's name, duties, expertise, compensation, replacement plan, existing policies, and board approval to purchase a new keyman insurance policy for the individual.

Uploaded by

badasserytech
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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KEYMAN QUESTIONNAIRE

Full name of life to be assured

Proposal number /Application number

1. Name of the employer company

2. Detailed nature of business /activities of the company

3. a) Full name of the Keyman

b) His date of birth

c) His academic and professional qualifications

4. a) Status /nature of Keyman’s duties.

b) Give full details of the Keyman’s duties.

5. What special knowledge /expertise does Keyman possess or why is the company so dependent on him?

6. What basis has been used to arrive at the sum proposed?

7. State employer’s turnover and gross & net profit over the last 3 years Year Turnover Gross Profit Net Profit
Turnover (G.P=N.P+Tax+Depreciation)
Replies such as “as per Balance sheet P & L A/c enclosed” not
acceptable. Summary must be given.
8. What are the prospects for the Keyman in the company?

9. Give details of the Keyman’s salary (including commission payment/ Year Salary Value of Perks, if any
profit sharing etc.) bonus, earned by him during value of last 3 years
10. Whether the company can train a person who can replace him and if so, within what time? State whether at present any person is
being trained to succeed him and if not, the reason for not doing so.

11. Who was the person in his place before and what were his qualifications, training and experience?

12. Likely loss that the concern may suffer on account of the death of the Keyman.

13. Is the Keyman or any member of his family is a shareholder of the company? Yes No

14. If yes, what is the holding in relation of the total issued capital?
No. of shares held________ % of the total shares issued ________
Keyman: ______________
Spouse: ______________
Children: ______________
Total: ______________

15. What are the details of the Keyman’s service agreement?

Attach copy of the agreement also.


16. Has the Board authorized the purchase of policy? Yes No
If yes, attach the copy of Board Resolution verified by the company officials.
17. What is the retirement date of the Keyman?
18. a) Does the company already hold any Keyman policies?
If so, give details
Name of Keyman __________________________
Policy no. _________________________________
DOC in force_______________________________
S.A. ______________________________________
b) Has the company simultaneously proposed KMI on the lives of any other key personnel?
If so, give details.

COMP/DOC/Jun/2021/286/6126
c) Does company intend to effect Keyman insurance policies on the lives of any other key personnel?
If so, give details.

19. Whether the above employee is also considered as Keyman in any other company? Yes No
If yes, give details thereof.

20. What permanent health or other sickness insurance arrangements have been /will be made for the Keyman?

21. If the company is an unquoted Public Limited Company or a Private Limited Company, give following details.
i) Total no. of shareholders__________________________________
ii) Total no. of employees ___________________________________

Place: __________________ __________________________________________________


Signature of Official authorized in Board
Date: ___________________ Resolution & his seal.

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