COMPREHENSIVE PERSONAL INSURANCE
PROPOSAL FORM
CALL: 1800 419 3000 (Mon to Fri: 9am to 5pm)
PROPOSER’S DETAILS OCCUPANCY & USE
FAX: 6835 7408
Yes No ❑
Insured’s Name (Mr/Mrs/Ms) NRIC No./Passport No. Nationality Date of Birth Marital Status Occupation Employer Correspondence address
Is the building occupied by yourself and your immediate family? Is it likely to be left unoccupied for more than 30 consecutive days in any one calendar year? Is it used for any business, trade or professional purpose? The building is occupied by Do you hire any domestic maid? If yes, they work on ❑ owner
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❑ ❑
❑ ❑
❑ tenant ❑ ❑ ❑ part time
❑ full time
SECURITY IN THE PREMISES
Postal Code Tel No. (Home) (Handphone) Email Address (Office) (Fax)
1) Is the property fitted with fire or smoke detector? 2) If Yes, are the fire / smoke detector connected to the alarm system? 3) Do you have a burglary alarm system installed at the property? 4) If Yes, is the maintenance under annual contract by the installer?
Yes ❑
No ❑
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❑
❑
❑ ❑ ❑
❑ ❑ ❑
SPOUSE DETAILS
Name (Mr/Mrs/Ms) NRIC No./Passport No. Date of Birth Occupation
5) Is the property protected by 24 hour manned security on site? 6) Do you have a safe at your premises?
TRAVEL EXPOSURE (FOR PERSONAL VALUABLES)
How often do you travel abroad? ❑ Monthly ❑ Quarterly ❑ Not more than twice a year
LOCATION OF RISK
What is the approximate number and value of items regularly taken on trips? ❑ Terrace ❑ HDB
MAINTENANCE & APPRAISALS (FOR PERSONAL VALUABLES)
Type of Dwelling ❑ Semi-detached ❑ Others (please specify)
❑ Detached ❑ Condominium
When was the last date your jewellery items wre checked for their conditions? Risk Location (if different from correspondence address) Yes Postal Code Are there any items over S$2,500 that have not been appraised in the last five years? ❑ No ❑
HOUSEHOLD CONTENTS (RATE: 0.35%)
WORKMEN’S COMPENSATION FOR DOMESTIC MAIDS
Please use the Schedule below to compute your sum insured.
Description Limit (S$)
Is cover required? Premium: Name
Yes ❑ S$25.00
No ❑
1. Improvements, eg. built-in cabinets, lightings 2. Dining Room Furniture 3. Lounge Furniture 4. Master Bedroom Furniture 5. Other Furniture 6. Entertainment Equipment eg. television, video 7. Photographic Equipment
S$ S$ S$ S$ S$
Nationality Passport No.
BUILDING (RATE: 0.06%)
Sum Insured S$ S$
PERIOD OF INSURANCE
Premium Built-in Area sq feet
Year of built
8. Domestic Appliances eg. refrigerator, microwave, washing machine S$ 9. Computer Equipment 10. Clothing 11. Blanket & Linen 12. Cutlery & Silverware* 13. Crystal, China & Glass* 14. Works of Art, Sculptures, Paintings* 15. Carpets & Rugs* 16. Musical Instruments 17. Antiques (including Furniture)* 18. Personal Collections Additional Items S$ S$ S$ S$ S$ S$ S$ S$ S$ S$
From Previous Insurer
DECLARATION
To Policy No.
I declare that: a) the dwelling is constructed of brick, stone or concrete; b) in respect of any risks to be insured: i. no loss, damage, injury or liability has arisen in the last five years; ii. no circumstances exist which render such risks abnormal; c) the above particulars to be true and correct and agree that they shall be the basis of the contract between the Company and myself.
Important Notice: 1. Statement pursuant to the Insurance Act or any subsequent amendments thereof: You are to disclose in this Proposal Form, fully and faithfully, all the facts which you know or ought to know in respect of the risk that is being proposed. Otherwise, the Policy issued hereunder may be void. 2. If this proposal is accepted or when the cover commences, it is fundamental and absolute Special Condition of this contract of insurance that for individuallyowned policies, the premium due must be paid to the insurer/broker/agent before the inception of the cover. 3. Neither the brochure nor the Proposal Form is a contract of insurance. However, your declarations or disclosures shall form the basis of the contract of insurance. The specific terms, conditions and exclusions applicable to this insurance are set out in the Policy, a copy of which is available upon request.
Total Sum Insured Total Premium
S$ S$
*Each item/pair/set shall not exceed $2,500 unless specifically declared and accepted by the Company. (For items exceeding S$2,500, please attach receipts. Different premium rates and terms may apply)
PERSONAL VALUABLES (RATE: 1.40%) Each item/pair/set shall not exceed S$2,500 unless specifically declared and accepted by the Company. All items exceeding S$2,500 each in value must be accompanied by receipts or valuation certificates. Different premium rates and terms may apply. Personal valuables refers to watches, jewellery and furs. Description Limit (S$)
1. 2. 3. 4. 5. 6. 7. 8. Total Sum Insured Total Premium
(Note: Rate is advisory and may be different depending on the risk profile) FOR OFFICIAL USE Premium for:Building Cover Contents Cover Worldwide Valuables Cover Workmen’s Compensation for Domestic Maid GST Total Premium Payable S$ S$ S$ S$ S$ S$
PL064-05/05
Signature of Proposer / Date
Premium
PERSONAL LIABILITY (FREE COVER)
Agent/Broker’ Name Code Contact No.
Limit of Liability:
S$500,000