Applicant/Insured Name (Individual or Entity):
Entity Type:
Individual
Partnership
Private Company
Public Company
Trust
Non-Profit
Other:
Principal Address (No P.O. Boxes):
Mailing Address (If different from Principal Address):
Primary Business/Occupation/Profession:
Date of Establishment/Birth:
Contact Person for this Application:
Contact Phone Number:
Contact Email Address:
Tax Identification Number/Equivalent:
Coverage Type | Requested (Y/N) | Proposed Limit of Indemnity/Sum Insured | Requested Deductible/Excess | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | Property (Physical Damage) | ||||
2 | General/Public Liability | ||||
3 | Professional Liability/E&O | ||||
4 | Directors & Officers (D&O) | ||||
5 | Cyber/Data Breach | ||||
6 | Motor Fleet/Vehicle |
Desired Effective Date of Coverage:
Existing Policy Expiration Date:
Requested Policy Term:
Broker/Agent Name (If applicable):
Provide a detailed description of all current and contemplated operations, products, and/or services:
List all geographic areas where operations occur (e.g., Country A, Region B):
Total Gross Revenue/Sales for the last fiscal year (specify currency):
Projected Gross Revenue/Sales for the current fiscal year (specify currency):
Total number of employees (Full-Time Equivalent):
Do you use subcontractors/external professionals?
If Yes, what percentage of your annual turnover is derived from subcontracted work?
What contractual indemnity/insurance requirements do you impose on them?
Do you adhere to any recognized Quality Management System (e.g., ISO Standards)?
If Yes, specify which one:
The date of certification:
Note: Failure to disclose prior claims or incidents may prejudice coverage.
Question | Yes/No | Details/Explanation (If Yes) | ||
|---|---|---|---|---|
A | B | C | ||
1 | Has the Applicant, or any principal/director, ever had an insurance policy refused, cancelled, or non-renewed? | |||
2 | Has the Applicant made any claim(s) or received notice of any circumstance/incident that may lead to a claim, regardless of fault or whether it was reported to an insurer? | |||
3 | Is the Applicant aware of any fact, circumstance, or allegation of a potential error, omission, or negligent act that has not yet resulted in a formal claim but could reasonably lead to one? | |||
4 | Has any past or present director/officer ever been the subject of any insolvency, criminal, or regulatory investigation? |
Are there any legal proceedings (civil or criminal), inquiries, or investigations currently pending against the Applicant or any of its principals/directors?
If Yes, provide full details:
Has the Applicant or any subsidiary ever been declared bankrupt, insolvent, or subject to any receivership, liquidation, or debt arrangement proceedings?
If Yes, provide full details:
Attach copies of the Applicant’s most recent audited financial statements or equivalent statutory accounts. (Required for entities.)
Document Name | Upload Fie | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Location Address(es) to be Insured:
Construction Type:
brick
concrete
steel frame
wood
Year Built:
Occupancy Details:
office
retail
manufacturing
warehouse
Fire Protection:
Full Sprinkler System
Partial Sprinkler System
Monitored Alarm
Smoke Detectors
None
Security Measures:
Alarms
Guard Services
Other:
PLEASE READ CAREFULLY BEFORE SIGNING:
I/We declare that the statements and particulars provided in this Application Form, and any attachments or supplements thereto, are true, complete, and correct to the best of my/our knowledge and belief, after due inquiry.
I/We understand that this Application Form and any accompanying information will form the basis of the insurance policy (should a contract be issued) and that any material misrepresentation or omission may result in the voidance of the policy ab initio (from the beginning) and denial of claims.
I/We hereby authorize the Insurer to make any investigations and inquiries necessary in connection with this application.
Authorized Signature:
To configure an element, select it on the form.