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: ___________________________)
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),
Liberty Insurance Pte Ltd