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

PRODUCT LIABILITY 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.
Where space is inadequate for full answers to be given, please attach separate sheet designating the relevant question and answer. Your latest annual financial report and all printed material relevant to your products must accompany this application.
PLEASE USE BLOCK LETTERS AND CROSS (X) IN APPROPRIATE BOX
DETAILS OF PROPOSER
Name of Proposer (in full) :
Address (Post	al):
Business/Occupation :							Business Registraton No :
Individual, co-partnership or corporation :
1. You are a	 MANUFACTURER  IMPOTER  DISTRIBUTOR  EXPORTER  OTHERS (PLEASE SPECIFY) :
2.(a) How many years have you been in business under the present name ?
(b) Have you or your principals ever been engaged in this or similar enterprises under a different name ?  Yes  No If 'Yes', please give full details
3.(a) Location of factories or stores at which products are manufactured.
(b) Location of factories or stores from which products are distributed.
4.(a) Give complete description of the products which are manufactured, sold, distributed by the applicant.
(b) Of what materials or principal components are each of these products composed ?
(c) Total number of products manufactured annually. * Please attach all printed materials describing the products.
5. Do you manufacture the complete products ?  Yes  No If 'No', what component parts are purchased by you ?

(PL/PF092018) 1

6. Do you assemble the products ?				 Yes		 No
7. Do you supervise the assemble of the products ?				 Yes		 No
8. Do you maintain and/or service the products ? If 'Yes', please give full details, including copy of your standard written service contract				 Yes		 No
9. Do you maintain quality control procedures ? If 'Yes', set forth a brief outline of such procedures.				 Yes		 No
10. Do you maintain complete inventory records reflecting shipment and/or delivery to consignees and/or serial and/or batch numbers reflected on the finished product and on shipment invoices ?  Yes  No
11. Can the date of manufacture of each product be identified by the factory number stamped on it ?				 Yes		 No
12. Do you keep samples of products involved in your quality control procedures ? If 'Yes', how long are samples retained ? 1 Year  2 Years  3 Years  4 Years  5 Years 				 Yes		 No
13. Has your product ever been subject to any inquiry or investigation by any Government Agency concerning the efficiency, adequacy of labeling, hazardous contents, or safety?  Yes  No If 'Yes', please give full details and results of such inquiry.
14. Has your product passed all standards set by the respective government department ? If 'No', please explain.				 Yes		 No
15. Has your product ever been ordered removed from the market by any Government authority? If 'Yes', please give full details.				 Yes		 No
16. What are the dates of your firm's financial year ?	From	to
17. Set forth annual total gross sales as to each product. (a) Last Financial Year (audited) From (Please attach copies of the audited annual report) (b) Estimate for Current Financial Year From (c) Estimate for Next Financial From	to to to
18. Set forth the percentage distribution of each product by country of destination.		Product Insured	Country		% Of Distribution
		19. Are you affiliated in any manner with any of your suppliers or distributors ? If 'Yes', please give full details.				 Yes		 No
20.(a) Is original installation of such products made by your employees ? (b) If 'No', does the installer supply parts not manufactured by you?				 Yes  Yes		 No  No
21. Do you issue guarantees and/or warranties to purchasers? If 'Yes', for what period do you guarantee and/or warrant your products ? Set forth full details and attach copy of your form of guarantee and/or warranty.				 Yes		 No
22. Do you agree to hold your dealers or distributors or firms harmless against claims or suits for personal injuries or property damage in connection with your products?  Yes  No If 'Yes', please provide copies of all hold harmless and indemnity agreements with your dealers, distributors and firms.
23. Are your products accompanied by any written brochures, instructions or other written statements? If 'Yes', please provide copies of the brochures, instructions or written statements.				 Yes		 No
24. Have you ever been sued or has any claim ever been made against you in connection with any of your products, whether or nor such products are the subject of this application for insurance?  Yes  No If 'Yes', state date and nature of claim or suit whether pending or resolved, and if resolved, manner of such resolution.
25. Is your company at present or has it in the past insured for any products liability risks? If 'Yes', please state :-				 Yes		 No
a) Name of insurer(s)
b) Limit of indemnity
c) Gross Premium
d) Deductible
e) Period of insurance
f) Extension (if any)

26.Has any application for insurance for products liability been declined or has any such insruance been cancelled or renewal refused or have special terms been imposed?  Yes  No If 'Yes', please give full details.
27. What amount of insurance indemnity do you require (list alternatives, if desired)? a) RM b) RM
28. Are you aware of any incidents, occurrences, or circumstances in connection with or involving products which are the subject of this application that are likely to result in claims against you?  Yes  No If 'Yes', please provide full details.
29. Have you acquired any entities within the last 5 years. If 'Yes', please provide full details.								 Yes	 No
30. Do you have a legal department ?								 Yes	 No
31. Can we conduct a physical inspection of your premises ?								 Yes	 No
a) Name
b) Designation
c) Tel No.
PAYMENT METHOD
Total Premium Paid: RM		Please select payment method.
 Cash
 JomPay	For payment via JomPay, please provide proo payment.			f	of
 Visa  MasterCard	Card No. - - -							Expiry Date m m / y y
Cardholder’s Name:
Date:		Cardholder’s Signature:
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: