Address: Level 36, Menara Bangkok Bank, 105, Jalan Ampang, 50450 Kuala Lumpur.

Address: Xxxxx 00, Xxxxxx Xxxxxxx Bank, 000, Xxxxx Xxxxxx, 00000 Xxxxx Xxxxxx.

Toll Free: 0-000-000-000 Tel.: 00-0000 0000 Fax: 00-0000 0000 E-mail: xxxx@xxxxxx.xxx.xx Website: xxx.xxxxxxxxxxxx.xxx.xx

Postcode

WORKMEN’S COMPENSATION INSURANCE PROPOSAL FORM

Berjaya Sompo Insurance Berhad (62605-U) (BSIB) is licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia.
IMPORTANT NOTICE
Non-Consumer Insurance Contract Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your trade, business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure for Non-Consumer Insurance Contract shall continue until the time your contract of insurance is entered into, varied or renewed with us. In addition to answering the questions in this proposal form, you are required to disclose any other matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this proposal form is inaccurate or has changed.
PLEASE USE BLOCK LETTERS AND CROSS (X) IN APPROPRIATE BOX
DETAILS OF PROPOSER
Name of Proposer (in full) :
Address (Postal):
Business/ Occupation :				Business Registraton No :
Period of Insurance : From to (Both Dates inclusive)
DEFINITION The term “Wages salaries and other earning’ means the employees’ total remuneration including overtime value of board and lodging, housing, accomodation, bonuses and any other pre-requisites in kind or money received by the employees in connection with their employment without any deduction in respect of Employees’ Provident Fund Contributions, Income Tax, Holidays with Pay or Contributory Pensions.
Item No.	Occupations of Employees	Est. No. of Employees	Estimated Total Annual Wages, Salaries, and Other Earings		For office use
			Total Premium		Rate (%)	Premium	Classification No.
					RM

(WC/PF 092018) 1

1. Place of Employment. In respect of Contract works, please state Title of Contract.
2. Does the above Schedule include all persons in your employment?  Yes  No
3. Are you involved in manufacturing, filling, breaking down of gun-powder, nitro-glycerine or any other explosives or toxic material?  Yes  No
4. a) Are you involved in mining, processing, manufacturing, distributing, storage and/or removal of pure asbestos and/or products made entirely or mainly of asbestos?  Yes  No b) Do you use products made entirely or mainly of asbestos?  Yes  No
5. Do you have any insurance in respect of your liability to your employees?  Yes  No If Yes, please give details.
6. Has any insurance company
a) declined your proposal?	 Yes  No
b) refused renewal of your policy?	 Yes  No
c) required and increased premium or imposed a special condition?	 Yes  No
If Yes, Please give details
9. Give full particulars for all injuries and/or death sustained by your employees during the past 3 years.
PAYMENT METHOD
Total Premium Paid: RM		Please select payment method.
 Cash
 JomPay	For payment via JomPay, please provide proof of payment.
 Visa  MasterCard	Card No. - - -				Expiry Date m m / y y
Cardholder’s Name:
Date:				Cardholder’s Signature:
SERVICE TAX (ST) - ST will be imposed on the applicable portion of the premiums due and payable.
PRIVACY NOTICE
The personal information including your personal, policy and financial details ("Personal Data") provided by and collected from you may be used and processed by us and our Group Companies1 (within or outside Malaysia) in order for us to provide our services and to operate and manage our function as an insurance company. By signing on this proposal form, you consent to the use and processing of your Personal Data for the purposes as stated in our Privacy Notice. If you represent a body corporate, you have procured the necessary consent for our use and processing of the Personal Data provided by you for the purposes as stated in our Privacy Notice. Please refer to the Privacy Notice for details of your Personal Data privacy rights and our rights of disclosure, which is also available at our website at xxx.xxxxxxxxxxxx.xxx.xx.
OPTION TO SUBSCRIBE TO CROSS-SELLING ACTIVITIES
You can extend your consent for us to use your Personal Data for cross-selling purposes within/with our Group Companies or our strategic business partners or selected third parties, by selecting:  Yes  No Take note that you can always choose to opt out of the cross-selling activities as described above (including marketing campaigns by any of our Group Companies) at any time by contacting BSIB at the contact number stated above. Note: 1Group Companies refer to Sompo Holdings Group and Berjaya Group, of which BSIB is also an affiliate.

DECLARATION BY PROPOSER
I/We declare and warrant that the answers/information provided in this proposal form are true and correct and I/We have not withheld any information or made any misrepresentation likely to affect the acceptance of this proposal and declaration which I/We agree shall be the basis of the contract between myself/ourselves and the Company. I/We shall undertake to notify the Company when there is any subsequent change to the information provided in this proposal form. A copy of the product disclosure sheet (“PDS”) is available at our website xxx.xxxxxxxxxxxx.xxx.xx. Please make sure that you have read and understood the contents of the PDS before purchasing the product.
Date	Proposer’s Signature
	(If the Proposer is a company, authorised signature(s) and chop)
FOR AGENT / OFFICE USE
Cover Note / Policy No.:
Intermediary:
Account No.:
Remarks: