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
* Required
1. Name of Proposer
*
(Nama Pencadang)
Your answer
Your e-mail address (alamat e-mail kamu)
*
Your answer
2. Address
*
(Alamat Surat Menyurat)
Your answer
3. Is the Proposer the main contractor or subcontractor or both
*
(Adakah Pencadang kontraktor utama ataupun sub-kontraktor)
Choose
Main Contractor (Kontraktor Utama)
Sub Conractor (Kontraktor Sub)
Both (Main & Sub-Con) Kedua-duanya (Utama dan Sub)
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)
Your answer
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)
Your answer
6. General description of business of the Proposer
*
6. Keterangan Umum usaha pencadang
Your answer
7. Annual Turnover (RM) ( last financial year )
7. Penjualan/Pendapatan Tahunan (RM) (tahun kewangan berlalu)
Your answer
7a.)Estimated Turnover RM ( current financial year’s projection )
7a.)(Anggaran Pendapatan RM (tahun kewangan terkini)
Your answer
7b.)Estimated Turnover RM ( next financial year’s projection )
7b.)Anggaran Pendapatan RM (tahun kewangan hadapan)
Your answer
8ai). Project Staff force : Technical
8ai). Daya Kakitangan Projek : Teknikal
Your answer
8aii)Project Staff force : Non-Technical
8aii) Daya Kakitangan Projek : Bukan Teknikal
Your answer
8bi. Annual Basis Staff Force: Technical
8bi. Daya Kakitangan Dasar Tahunan: Teknikal
Your answer
8bii. Annual Basis Staff Force: Non-Technical
8bii. Daya Kakitangan Dasar Tahunan - Bukan Teknikal
Your answer
9. a) Is the Proposer a subsidiary of another entity
9. a) Adakah Pencadang sebuah subsidiari untuk syarikat yang lain
Your answer
9. b) Does the Proposer have any subsidiary
9. b) Adakah Pencadang memiliki sebuah subsidiari (Anak Syarikat)
Your answer
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