FIRE INSURANCE APPLICATION FORM INDIVIDUAL CLIENT

Transcription

1 FIRE INSURANCE APPLICATION FORM INDIVIDUAL CLIENT Client information as mandated under the Phil. Anti-Money Laundering Act (AMLA) R.A No as amended. Complete information is required before a policy is issued. Residential Commercial Warehouse Industrial Complete Name: Sex: Male Female Citizenship: Residence Address: Civil Status: Single Separated Married Widow Date of Birth: Telephone/Mobile/Fax No.: Place of Birth: Address: SSS, GSIS, Driver s License or Passport No. (For Driver s License and Passport, please indicate Date of Expiry ): Name of Business/Employer: Occupation/Designation: TIN: Business/Employer Address: Contact No.: Fax No.: Nature of Business (If self-employed): If unemployed, please state source of funds: Name of Beneficiary/Relationship, if applicable: Address of Beneficiary: Please check your preferred mailing address: Residence Address Business Address

2 UNDERWRITING DETAILS BUILDING Address of Property to be Insured Description of Building Nearest Landmark Properties to be Insured Amount of Insurance Applied for Age of Building No. of storeys/floors Basement No. of detached buildings Total Ground Floor Area The Property is Occupied as Residential Warehouse Commercial Industrial *For properties occupied as commercial and industrial, please indicate nature of business. For warehouse, indicate the type of goods in storage The roof is made of? GI Sheet Tegula Reinforced Concrete Boundaries (Houses, Buildings or Street surrounding the property) The exterior walls are made of? Concrete/Concrete Hollow Blocks Concrete/Concrete Hollow Blocks with Timber Occupancy No. of Storeys Roof Exterior Walls Front Right Left Rear CONTENTS Furnitures, Fixtures, Fitting Amount: Description : Leasehold Improvement / FFFE Amount: Description : Machinery / Equipment Amount: Description : Stocks Amount: Description : Others (Please Specify) Amount: Description : Desired Coverage Fire & Lightning Typhoon Extended Coverage Earthquake Flood Riot, Strike, Malicious damage Robbery & Burglary With Grills Yes No With Security Guards Yes No With Perimeter Fence Yes No Height of Perimeter Fence

3 Is the property mortgaged? No Yes, Mortgagee:_ Interest on the property Owner Lessee Part Owner Mortgagor Contractor Others (Please specify) Have you had a fire loss or any other losses (e.g. earthquake, typhoon, flood, etc.) in this or other premises? Past 3 years Yes No Past 5 years Yes No Date of Loss : Nature of Loss/Extent: Amount of Loss/Received: Address of Property: Insurance Company: SPECIAL HAZARDS: (For Commercial, Warehouse & Industrial Occupancies) None Yes No Explosive Dusts: Yes No Ovens, Furnaces, Heaters: Yes No Radio Active Materials Yes No Flammable Solvents: Yes No Smoking Control Yes No Flammable Gases: Yes No Cutting & Welding Yes No Others: Storage Arrangement: (For Warehouse Occupancy) Separate from production areas Yes No Maximum storage height: UTILITIES Fuel: LPG Coal Electric Electricity: Distributor Generator Yes No Capacity: Boilers: Hot Water Steam BUSINESS INTERRUPTION Plant operates Shifts days per week No. of Employees Production bottleneck Yes No Where Alternate production facilities Yes No Stock of raw materials weeks Availability of raw materials Replacement time of machinery months PROTECTION Automatic sprinklers Yes No Hand extinguisher Yes No Inside hose reels Yes No Yard hydrants Yes No Water supply to automatic sprinklers, inside hose reels and yard hydrants Private Yes No Watchman service Yes No Public Yes No Fire detection system Yes No Private fire brigade Yes No PUBLIC FIRE DEPT. Distance Stock of finished products weeks Critical utilities _ Replacement time of building months

4 (FOR UNDERWRITING USE ONLY) Location Code: District No./Name: Block No.: Risk No.: Earthquake Zone: Do you have an existing agent with BPI/MS? None Yes Agent s Name: Note: This Application, if approved, shall form part of and shall be the sole basis in issuing the Fire Insurance Policy. Any material fact disclosed or misrepresented at the time this Application is accomplished, shall exempt the Insurer from any liability caused or brought about by such undisclosed or misrepresented material fact. I hereby authorize BPI/MS to inquire about and investigate all the declared information from whatever sources BPI/MS may consider appropriate and use any contact details to communicate to me for whatever purpose (such as customer satisfaction surveys, etc.). Signature of Applicant Date Financial product/s of BPI/MS is/are not insured by the Philippine Deposit Insurance Corporation and is/are not guaranteed by the Bank of the Philippine Islands. PAYMENT OPTIONS Cash BPI Debit Card BPI Express Online Credit Card Please refer to the Payment Facilities page for more details.

5 To be accomplished by BPI personnel TRACKING FORM Client s RM No.: Referrer s name: Referrer s Employee No.: Referring Branch code: Referring Branch name: Dealer s name: