Miscellaneous Casualty Insurance

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Product Type

Full Name

Address

Email Address

Contact Number

Term of Insurance (Start Date)

Term of Insurance (End Date)

Nature of Business Operation

Area of Operation/Location of Risk/s

Supporting Documents

Sum Insured/Limit of Liability

Total no. of sqm

Years in operation

Usage of the equipment per unit

Pictures (if any)

Other Informations

Scope of work

Contract of Agreement

No. of employees to be deployed

Extensions of Cover Desired

Third Party Claims History

Has any Third Party Liability claim been made against the Insured during the last five years for Bodily Injury or Property Damage?

Dates

Description of Accident

Number of Casualties

Property/ies Damaged

Amount of Claim

Status of Case

Equipment / Units to be Insured

Note: Full description of equipment/units with corresponding value per unit

Document/s

Year Model

Type

Serial Number

Motor Number

Plate Number

Control No./Unique Identification

Amount per unit

Total Sum Insured / Invoice / Appraised Value

Additional Information

Please provide the previous and outstanding claims record including details for the past five (5) years of operation

Please provide brief details of any risk management/loss prevention measures being undertaken

Please give any other material informations which you feel Underwriter’s should be made aware of

Preferred Branch

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Miscellaneous Casualty Insurance

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