Fax this completed form to OMNI at: (632) 810-0761
2 Pages
OMNI Group of Companies
(Insurance Brokerage Services – Since 1971)
OMNI International Consultants, Inc. OMNI Expat Benefits Association, Ltd. OMNI Capital (Far East), Ltd.
Householders Comprehensive Purchase Form
A. On Contents and/or Building
Pays the insured, Building owner or tenant, who owns or is responsible for loss or damage to the insured property
caused by fire, lightning, all perils of nature, extended cover, riot, strike, civil commotion, malicious damage,
burglary and water damage. Also pays for loss or damage to contents temporarily removed for maintenance or
repair up to 15% of Contents sum insured, mirrors, interior decorations, sanitary fixtures/fittings, servant’s
property up to P5000, frozen food up to P1500, alternative accommodation or loss of rent up to 10% of sum
insured, debris removal up to 10% of Building sum insured and valuables up to 33% of Contents sum insured
limited to 5% of Contents sum insured per item.
VALUE OF PROPERTY TO BE INSURED
BUILDING CONTENTS
B. Family Public Liability for Resident Tenant or Owner
Protects Insured against legal liability claims arising from the premises within the Philippines resulting to bodily
injury and/or property damage to third parties up to a limit of P500,000 any one event. Additional benefits are
servant’s medical payments up to P5000 to include litigation costs and expenses.
OPTIONAL COVERAGE:
YES ( ) Increase Family premises only Liability from standard P500,000 to P1,000,000 & add P500 premium
(OR) change ( ) to Family Philippines-wide Liability for following limits & costs:
P500,000 (+P750-prem) or P1M (+P1500-prem) or P2M (+P2500-prem) or none
C. 24-hours Worldwide Family Personal Accident for Resident Tenant or Owner
Covers accidental bodily injury resulting to death or permanent disablement with a medical or funeral expenses benefit.
Sum Insured: Below is 1 UNIT of benefit as provided in the standard policy. You may take up to 5 units.
One Unit Covers Death/Disablement Medical/Funeral Aggregate Limit
Expense
Insured & Spouse each P100,000 P10,000 P110,000
Children P 50,000 P 5,000 P150,000
Househelpers P 25,000 P 2,500 P 50,000
OPTIONAL COVERAGE:
One (1) Unit of standard Family Accident is provided free. Additional Units may be added for P250 per additional Unit up
to a maximum of five (5) Units. Number of Additional Units to be added <<< Maximum of 4 Additional Units.
D. Optional All Risks Personal Properties for Resident Tenant or Owner (limited to maximum of 2-times
insured value of Building and/or Contents above) covers “All Risks” loss or damage to personal effects &
valuables consequent upon any sudden & unforeseen event not excluded in the policy. A list with description &
values must be supplied. Insures On & Off-premises Philippines-Wide or Worldwide based on option/s taken. A
deductible of 1% of sum insured applies to any one loss.
VALUE OF PROPERTY TO BE INSURED ALL RISKS
PHILIPPINES WORLDWIDE
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Where/How did you learn of OMNI?
Proposer’s Name Insurance date
Occupation Employer
Address
Tel: Fax e-mail
Describe building construction
Type of roof Security? # stories
Describe surroundings: If adjacent to other building/s, indicate distance/occupancy/type of each structure
Front Rear
Left Righ
t
Total Annual Premium Cost inclusive of Taxes and Policy Fee
Notes
1. Rate above is for a class “A” risk located in the Metro Manila area. Class “A” risks outside of Metro Manila are
higher and quotations may be requested separately.
2. Values declared are assumed “Sound” or “Fair Market” unless otherwise applied for and accepted by the
underwriters. Therefore depreciation will be applied when calculating any claim settlement. To apply for coverage
insuring the properties at “Reinstatement as New” values, all properties must be declared at current new
replacement cost.
Place the insurance quoted herein as accepted by my signature below.
Attach Check Payable to “OMNI Insurance Brokers” or await invoice
Signature of
Proposer Date
Proposer’s Special Instructions/Remarks:
IMPORTANT INFORMATION!
OMNI will confirm receipt of this request for insurance purchase/placement. Only insurance companies can approve or
reject your request for final policy placement --based upon the particulars you have supplied. OMNI will send to you details
of the insurance company’s official confirmation.
You MUST complete, originally sign and return this purchase form to OMNI by mail or courier. It will be forwarded to the
insurance company for acceptance and policy issuance. Applications sent by fax that specifically request early temporary
cover will be expedited.
Complete details of the coverage are stipulated in the actual Policy documents provided by the insurance company. These
must be thoroughly read by all policyholders.
Refer to the OMNI Business Terms for further guidance, if needed.
OMNI Capital or OEBA OMNI International Consultants
4/Floor Galuxe Bldg., 8-10 On Lan St. 3/F Corinthian Plaza Bldg., 121 Paseo de Roxas St.,
Central Hong Kong Legaspi Village, Makati Philippines 1262
Tel: (852) 2523-2767 Fax: (852) 2810-1957 Tel: (632) 810-0487 Fax: (632) 810-0761
Send e-mail to info@omnibrokers.com.ph | Website: www.omnibrokers.com.ph
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