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

ERECTION ALL RISKS 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 Registration:	ST Registration No :
Business, Trade or Occupation :	Email :
Telephone No. (Office) :	Fax No :
PARTICULARS OF THE RISK TO BE INSURED
1. Title of contract (If project consists of several sections. specify section(s) to be insured) :
2. Location of erection site Country : City,Town,Village :
3. Please indicate which of the Nos. 4 to 9 below is the “Proposer” of the insurance, which parties are to be declared as “insured “ in the policy Proposer No : Insured No(s):
4. Principal Name(s) : Address(es) :
5. Main Contractor Name(s) : Address(es) :
6. Subcontrator Name(s) : Address(es) :
7. Manufacturer(s) of main items Name(s) : Address(es) :
8. Firm Supervising erection Name(s) : Address(es) :
9. Consulting engineer Name(s) : Address(es) :
10. Exact description of the property to be erected (if second hand items are to be erected , please state). :

(EAR/PF092018) 1

11. (a) Period of insurance Commencement of insurance Duration of pre-storage : Months Commencement of erection work Duration of eretion/construction : Months Duration of testing : Weeks (b) if maintanance coverage required Duration of maintenance : Months Type of coverage required : Termination of insurance :
12. Have plans, desgins and materials of kind used in this picture been usd and /or tested in (a) Previous Constructions  Yes  No (b) Previous Constructions by the Contractor(s)  Yes  No *please give details of similar projects carried out by Contractor(s)
13. (a) Is this an extension of an existing plant ?  Yes  No (b) Will operations of existing plant continue during erection period ?  Yes  No (Enclose plans where available )
14. Have the buildings and Civil Engineering works already been completed ?  Yes  No
15. Work to be carried out subcontractors :
Please also give answers to Nos. 16 to 21 as far as information obtainable:
16. Is there any aggravated risk of : Fire :  Yes  No Explosion :  Yes  No *if so, give details :
17. Ground water level :
18. Nearest river,lake,sea,etc : Name : Distance from site : Level of such river, lake, sea, etc : : Xxx water : Mean water Highest level recorded : mean level of site :
19. Meteorological conditions : Rainy seasons from : to Max. rainfall(mm) : Per hour : Per day : Per Month: Max. wind velocity : Storm frequency  Low  Medium  High
20. Hazards of earthquake, volcanic, tsunami (a) Is there a history of volcanism, tsunami at the site ?  Yes  No (b) Have earthquake,etc been observed in this area ?  Yes  No *if so, please state intensity Magnitude Subsoil conditions:  rock  gravel  sand  clay  filled site Other type Do geological faults exist in the vicinity ?  Yes  No
21. Estimate , if possible, the probable maximum loss, expressed as a percentage of the sum insured , in a single occurrence (a) Due to earthquake : (b) Due to fire : (c) Due to other cause (please specify) :
22. Is coverage of constructions/erection equipment (scaf folding,huts,tools,etc) required ?  Yes  No *please give brief description and state value under No.28,3
23. Is coverage of Construction/Erection machinery (ex-cavators,cranes,etc) required ?  Yes  No *please attch list of major machines showing individual new replacement values and state totalvalue under No. 28,4.
24. Are existing buildings and /or structure on or adjacent to the site,owned by or held in care ,custody or control of the constractor(s) or the principal to be insured against loss or damage arising out of or in connection with the contract work? State limit under No 28.5.  Yes  No *Exact description of there buildings/structures :
25. Is Third party liability to be included ?  Yes  No *Give bried description of surrounding and existing building and / or structures not belonging to the Principal or Contractor(s) enclose maps, if possible). State limits under No 28,Section II.
26. Do you wish cover to included extra charges (in case of loss) for : (a) Express freight ,overtime, night work, work on public holidays ?  Yes  No (b) Air freight ?  Yes  No
27. Give details of any special extension of cover required.:
28. Plese state here under the amounts you wish to insure or where applicable th limits of indemnity required (cf. Policy wording, section I, Memo 1 and section II) : Currency :
	Items to be insured	Sums to be insured (state below separately )
	1. Erection works,split up as follows:
Section 1- Material Damage	1.1. Items to be erected 1.2. Freight
	1.3. Customs Duties and Dues
	1.4. Cost of erection
	2. Civil Engineering Works
	3. Construction/erection equipment

4. Clearance / erections equipent (limit of indemnity)

5. Property located on the principal’s premises or on the site, belonging to the principal or held in care custody or control (Limit of indemnity see Memo 4 of policy )

Total sum to be insured under section 1

Please indicate limits of indemnity required for the following perlis:

Risk

Limit of indemnity

Earthquake, volcani

sm

, ts

una

m

i

Storm,cyclone,flood,inundation, landslide

Section II – Third Party Liability

Insured

Limit of indemnity

Bodily injury - any on

e

per

son

Bodily injury – total

Property Damage

Or alternatively Combined single lim

it

of

1. Limit of indemnity in respect of each and every loss or damage and or/series of losses or damage arising out of any one event. 2. Limit of indemnity in respect of any one accidents or series of accidents arising out of one event.

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: