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Microsoft word - burglary proposal-may05.doc

Liberty Insurance Pte Ltd
BURGLARY – Proposal Form
Statement pursuant to Section 25(5) of the Insurance Act (Cap. 142) (or any subsequent amendments
thereof) – You are to disclose in this Proposal Form fully and faithfully all facts which you know or ought
to know, otherwise the Policy issued hereunder may be void.

Intermediary:
___________________________ Code: _______________ Tel No: ________________
Email: _______________________________________________________ Fax No: ________________
Please write or tick ‰ where applicable.
1. The Proposer
Full Name ____________________________________________________________________________
Mailing Address _______________________________________________________________________
_______________________________________________________________________
Tel _______________ Fax ________________ Email ______________________________________
Nature of Business (Please provide full description.) ___________________________________________
_____________________________________________________________________________________
Business Registration No. ______________________ Number of Years in Business ___________

2. Period of Insurance
From ______________________________ To ___________________________
3. The Risk Premises

Location _____________________________________________________________________________
_____________________________________________________________________________

Use of Premises ‰ Dwelling ‰ Office ‰ Shop ‰ Warehouse
‰ Manufacturing ‰ Engineering ‰ Others, please specify:
_______________________________________________________________ Construction of Premises (a) Walls ‰ Brick ‰ Concrete ‰ Asbestos ‰ Open-sided ‰ Others, please specify: __________________________________________ (b) Roof ‰ Tiles ‰ Concrete ‰ Asbestos ‰ Zinc ‰ Others, please specify: _________________________________________ (c) Building Frame ‰ Metal ‰ Concrete ‰ Wooden
4. Security Systems of Premises:
Surveillance Camera ‰ Yes ‰ No
● Burglar Alarm System ‰ Yes ‰ No
If yes, state (a) Brand _______________________________________________________________ (b) Whether connected to a central monitoring station ‰ Yes ‰ No ● Grilled Doors ‰ Yes ‰ No ● 24 Hours Watchman Services ‰ Yes ‰ No ● Security Checkpoint ‰ Yes ‰ No ● Others, please specify _______________________________________________________________

5. Property to be Insured
Interests Sum Insured (S$)
______________________________________ ‰ Full Value _______________
______________________________________ ‰ First Loss _______________ 6. Claims Experience
Please give full particulars of all losses for the last 5 years:
Date of Loss Nature of Loss Amount Claimed (S$)
__________ __________________________________ __________________
__________ __________________________________ __________________

7. Other Information
a Are there any high value/attractive goods (e.g. birdnest, ginseng, sharksfin,
abalone etc) stored in the Premises? If yes, please state the types of high value/attractive goods __________________ __________________________________________________________________ If yes, please state its nature of business ________________________________ c Does the building adjoin any other Premises? If yes, please state its nature of business ________________________________ d Is there any insurance in force on the same property for the same period of insurance being proposed? If yes, please state (i) Name of Insurer ________________________________ (ii) Sum Insured (S$) _______________________________ e Has any Insurance Company ever refused your Burglary Insurance Proposal or f Has your insurance been cancelled solely or in part due to a breach of premium
8. Details of Expiring Insurance
Please provide the following information:
(a) Insurer _________________________________ (b) Sum Insured (S$) ____________________ (b) Annual Premium (S$) ______________________ (d) Excess ____________________________ (e) Special Terms and Conditions ______________________________________________________
_______________________________________________________________________________
(f) Expiry Date _____________________________________________________________________

Premium Payment Warranty:
Please note that the total premium due must be paid and actually received
in full by the Company (or the intermediary through whom this Policy was effected) within 60 days from
the inception date of the coverage, failing which the Policy shall be automatically terminated and the
Company shall be entitled to a pro-rata time on risk premium subject to a minimum of S$25.00.
Declaration
WE/I DO HEREBY DECLARE AND WARRANT that the answers/information given above in every
respect are true and correct and we/I have not withheld any information likely to affect the acceptance of
this Proposal and we/I agree that this Proposal & Declaration shall be the basis of the Contract between the
Company and ourselves/myself and we/I further agree to accept the Company’s Policy subject to the terms,
exclusions and conditions to be expressed therein, endorsed thereon or attached thereto.
___________________ _________________________________
Date Signature of Proposer & Company Stamp
The liability of the Company does not commence until this Proposal has been accepted by the Company.

Underwriter’s Quotation
Class _______ Insured __________________________________ Date of Proposal Form ____________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ __________________ _______________________________________ Quotation Date Signature Validity Date: 14 days from quotation date. (Underwriter: ___________________________)

Source: http://www.libertyinsurance.com.sg/wp-content/uploads/2011/09/Business_Burglary_Proposal.pdf

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Characteristics and Management of Selected Bioterrorism Agents Disease/ Incubation Clinical Syndrome Lethality Diagnostic Tests Treatment2 Chemoprophylaxis BACTERIAL AGENTS Cutaneous: Evolving skin lesion 20% if untreated, Gram stain and culture of Ciprofloxacin; possibly up to 60 (face, neck, arms), progresses blood, pleural fluid, CSF, doxycycline. doxycycline

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Condition de Condition de Stabilité de Type de prélevement d'exécution Nomenclature Cotation prélèvement du conservation avant l'échantillon avant traitement traitement Exécutions possibles : [C] ADVIA CENTAUR XP 1 Exécutions possibles : [C] ADVIA CENTAUR XP 1 Exécutions possibles : [C] ADVIA CENTAUR XP 2 Exécutions possibles : [C] ADVIA 1800 (2),

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