SINGLE CONTRACT COMPREHENSIVE GENERAL LIABILITY INSURANCE PROPOSAL FORM

IMPORTANT :
I. PURSUANT TO SECTION 149(4) OF THE INSURANCE ACT 1996 – You are to disclose in this proposal form, fully and faithfully all the facts which you know or ought to know, otherwise the policy issued hereunder ma be void.
II. Signing of this Proposal does not bind the Company to offer or the Proposer to accept, Insurance, but it is agreed that this Proposal shall be the basis of any insurance issued.
III. If there is insufficient space to complete the Proposal, please attach additional sheets.

SIMON POON AGENCY & Associated Principal application

1. Name of Proposer

(Nama Pencadang)

This is a required question

Your e-mail address (alamat e-mail kamu)

This is a required question

2. Address

(Alamat Surat Menyurat)

This is a required question

3. Is the Proposer the main contractor or subcontractor or both

(Adakah Pencadang kontraktor utama ataupun sub-kontraktor)

This is a required question

4. Name of Principal (party for whom the Proposer has contracted to do the work)

(Nama Prinsipal (pihak untuk siapa pencadang telah dikontrak untuk membuat kerja)

This is a required question

5. List additional parties to be mentioned in the policy as co-insured and their relationship contractually to the Proposer

(5. Senarai parti tambahan yang akan dinyatakan dalam dasar sebagai co-diasuransikan dan hubungan mereka kontrak kepada pencadang)

This is a required question

6. General description of business of the Proposer

6. Keterangan Umum usaha pencadang

This is a required question

7. Annual Turnover (RM) ( last financial year )

7. Penjualan/Pendapatan Tahunan (RM) (tahun kewangan berlalu)

This is a required question

7a.)Estimated Turnover RM ( current financial year’s projection )

7a.)(Anggaran Pendapatan RM (tahun kewangan terkini)

This is a required question

7b.)Estimated Turnover RM ( next financial year’s projection )

7b.)Anggaran Pendapatan RM (tahun kewangan hadapan)

This is a required question

8ai). Project Staff force : Technical

8ai). Daya Kakitangan Projek : Teknikal

This is a required question

8aii)Project Staff force : Non-Technical

8aii) Daya Kakitangan Projek : Bukan Teknikal

This is a required question

8bi. Annual Basis Staff Force: Technical

8bi. Daya Kakitangan Dasar Tahunan: Teknikal

This is a required question

8bii. Annual Basis Staff Force: Non-Technical

8bii. Daya Kakitangan Dasar Tahunan - Bukan Teknikal

This is a required question

9. a) Is the Proposer a subsidiary of another entity

9. a) Adakah Pencadang sebuah subsidiari untuk syarikat yang lain

This is a required question

9. b) Does the Proposer have any subsidiary

9. b) Adakah Pencadang memiliki sebuah subsidiari (Anak Syarikat)

This is a required question