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 | ||
|---|---|---|---|---|---|
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?
Do you adhere to any recognized Quality Management System (e.g., ISO Standards)?
Note: Failure to disclose prior claims or incidents may prejudice coverage.
Question | Yes/No | Details/Explanation (If Yes) | |
|---|---|---|---|
Has the Applicant, or any principal/director, ever had an insurance policy refused, cancelled, or non-renewed? | |||
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? | |||
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? | |||
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?
Has the Applicant or any subsidiary ever been declared bankrupt, insolvent, or subject to any receivership, liquidation, or debt arrangement proceedings?
Attach copies of the Applicant’s most recent audited financial statements or equivalent statutory accounts. (Required for entities.)
Document Name | Upload Fie | ||
|---|---|---|---|
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: