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

BOILER AND PRESSURE VESSEL 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):
NRIC No.:	E-Mail
ST Reg. No.
Business, Trade or Occupation	Business Registration:
Telephone No. (House)	Handphone No.
Telephone No. (Office)	Fax No.
PARTICULARS OF THE RISK TO BE INSURED
Address of plant :
Nature of business :
Name of business :
Name of chief engineer or plant manager :
Nearest railway station/ airport :
Period of Insurance : From            To
1. Has any of the boiler and pressure vessel plant to be insured previously been covered by other companies under boiler policy or machinery insurance policy? ⬜ Yes ⬜ No If so, which items of the specification and by what companies?
2. Does the specification include all the boiler and pressure vessel plant coverable under a boiler and pressure vessel policy ? ⬜ Yes ⬜ No If not, please indicate which items are excluded and why ?
3. Did an accident ever occur to your boiler and / or pressure vessel plant ? ⬜ Yes ⬜ No If so, give full particulars.
4. Do you wish to include the main stream and feed water piping ? ⬜ Yes ⬜ No
5. Are all the items in good condition? ⬜ Yes ⬜ No If not, give particulars of defects , if any.

(BAPV/PF092018) 1

6. Which part of the plant is subject to Periodical inspections ? Date of last inspection :
7. What is the maximum load on safety valve ?     psi What is the working pressure ?            bar
8. Are boiler attendants solely employed on the boiler plant? ⬜ Yes ⬜ No If not, what proportion of their time is reserved for other duties?
9. If to be insured , please indicate amount ( limit of indemnity ) applicable to surrounding property/ third party liability (property and bodily injury ).
Specification of Items to be Insured
Item no.	Maker's name and No.	Type of boiler or pressure vessel Please indicate for boilers: whether vertical, horizontal fire-tube or water- tube fired and unfired vessels: kind of vessel, dimensions and for what purpose used	Year of manuf acture	Steam output (tons/h)	Pressure (psi)	Kind of fuel	Sum Insured Please state current cost of replacing the item by a new item of the same kind and capacity plus freight charges, customs duties and costs of erection
Total sum insured :
(see para 10) plus amount for SP/TPL:
Total sum insured including SP/TPL:
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	Signature of the Proposer
	(If the Proposer is a company, authorised signature(s) and chop)
FOR AGENT / OFFICE USE
Cover Note / Policy No.:
Intermediary:
Account No.:
Remarks: