Fillable Printable Marsh Bizsecure Insurance Proposal Form
Fillable Printable Marsh Bizsecure Insurance Proposal Form
Marsh Bizsecure Insurance Proposal Form
MARSH BIZSECURE INSURANCE PROPOSAL FORM
DESCRIPTION OF PREMISES
Location of Risk(s) :
(if different from above)
Occupied as :
Please tick where applicable :
Construction of Wall : -
Brick & Concrete
Brick & Timber or Corrugated Iron
Timber only
Construction of Roof : -
Tiles/Concrete/Asbestos
Metal Sheets
Others
Fire Protection : -
Sprinkler
Hose Reels
Extinguishers
Smoke Detectors
Fire Alarm - Local/Connected
∗
Security : -
Burglar Alarm - Local/Connected
∗
Watchman/Security Guards
∗
on the Premises at night
PARTICULARS OF PROPOSER
Name of Company :
Correspondence Address :
Website :
Telephone Number :
Fax Number :
Description of Business/Trade :
Period of Insurance : From To
∗
Please delete where appropriate
CLASSES OF INSURANCE REQUIRED
SECTION 1 : INDUSTRIAL ALL RISKS
SECTION 1.1 : MATERIAL DAMAGE
INTEREST TO BE INSURED AMOUNT TO BE INSURED
1. Building
S$
2. Furniture, Fixtures, Fittings, Renovations and All Other Contents
S$
3. Stock In Trade
S$
4. Plant & Machinery
S$
5. Others (Please specify)
S$
Total S$
SECTION 1.2 : BUSINESS INTERRUPTION
INTEREST TO BE INSURED AMOUNT TO BE INSURED
1. Basis of Settlement
1.1. Gross Revenue/Rental/Profit* S$
1.2. Professional Fees S$
1.3 Additional Increase Cost of Working S$
2. Increase Cost of Working
2.1 Increase Cost of Working S$
2.2 Professional Fees S$
Total S$
Indemnity Period Required Months
Dependency of Suppliers/Customers
Please provide us with a list of your Suppliers and Customers and the percentage (%) of Gross Profit that each party
contributes.
SECTION 2 : COMPUTER/ELECTRONIC EQUIPMENT
INTEREST TO BE INSURED AMOUNT TO BE INSURED
1. Material Damage (Computers etc)
S$
2. Cost of Reinstating Data
S$
3. Increase Cost of Working
S$
4. Laptops
S$
Total
S$
Cover Required (Please Tick Where Applicable)
Anywhere in Singapore Worldwide
SECTION 3 : MONEY
INTEREST TO BE INSURED AMOUNT TO BE INSURED
1. Money in Transit Anywhere in Singapore
S$
2. Money in the Premises during & after Business Hours
(Money to be kept in Safe/Drawer/Cabinet/ Cash Register outside Business
Hours)
S$
Total Carryings
S$
SECTION 4 : FIDELITY GUARANTEE
INTEREST TO BE INSURED AMOUNT TO BE INSURED
If cover is required, you are required to complete a separate Proposal Form for
underwriting. Cover is not effective until confirmation by Insurer.
S$
No. of Employees :
SECTION 5 : GROUP PERSONAL ACCIDENT
PARTICULARS OF EMPLOYEES TO BE INSURED AMOUNT TO BE INSURED
Name :
Date of Birth :
Occupation :
NRIC No. :
S$
Name :
Date of Birth :
Occupation :
NRIC No. :
S$
Name :
Date of Birth :
Occupation :
NRIC No. :
S$
SECTION 6 : WORK INJURY COMPENSATION
CATEGORIES OF EMPLOYEES TO BE INSURED ESTIMATED ANNUAL WAGES
1. Management/Administrative/Clerical Employees (Non-Manual)
Description of Occupation :
No of Employees in this Category :
S$
2. Sales/Marketing Employees
Description of Occupation :
No. of Employees in this Category :
S$
3. Manual Employees
Description of Occupation :
No. of Employees in this Category :
S$
4. All Others
Description of Occupation :
No. of employees in this category :
S$
5. Part-Timers/Temporary Employees :
Description of Occupation :
No. of Employees in this Category :
S$
Total S$
SECTION 7 : PUBLIC LIABILITY
LIMIT OF INDEMNITY AMOUNT TO BE INSURED
Any One Occurrence
Any One Period
S$
Unlimited
SECTION 8 : CARGO INLAND TRANSIT
INTEREST TO BE INSURED AMOUNT TO BE INSURED
S$
(Max Per Conveyance)
Estimated Annual Turnover : S$
SECTION 9 : DIRECTORS & OFFICERS LIABILITY
Please answer ALL questions and tick whenever appropriate.
Agree Disagree
Your Company is incorporated in Singapore for at least a year.
Your Company is non-listed.
Your Company has a positive net worth and operating profit for the past year.
Your Company does not have any assets, revenue or employees in USA and/or Canada.
The latest accounts of your Company do not have an audit qualification.
There are no claims or circumstances which might give rise to a claim.
Limit of Indemnity Required
S$100,000
S$250,000
S$500,000
S$750,000
Estimated Annual Turnover : S$
CLAIMS EXPERIENCE
Have you suffered any loss and/or damage under any of the above classes of Insurance?
No
Yes (please provide details below)
Date of Accident Details of Accident Claim Amount (S$)
DECLARATION
I/We warrant that the above statements made by me/us or my/our behalf are true and complete and I/We agree
that this proposal together with any other information supplied shall be the basis of and are considered as incorporated
within the policy between me/us and the Insurer.
Signature
Designation
Date
