PROFESSIONAL INDEMNITY PROPOSAL FORM ESTATE AGENTS

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1 PROFESSIONAL INDEMNITY PROPOSAL FORM ESTATE AGENTS Allianz General Insurance Company (Malaysia) Berhad is licensed under the Financial Services Act 2013 (FSA) and regulated by Bank Negara Malaysia (BNM). NON-CONSUMER INSURANCE CONTRACT Pursuant to Paragraph 4 of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for purposes 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 contract, claim denied or reduced, terms changed or varied, or contract terminated. This duty of disclosure shall continue until the time the contract is entered into, varied or renewed. Account No: Policy No: Cover Note No: IMPORTANT NOTICE TO PROSPECTIVE POLICY Policy owners are advised to read the policy carefully and understand the contents therein. You are encouraged to seek clarification from the insurer if necessary Signing of this Proposal does not bind the Company to offer or the Proposer to accept insurance, but it is agreed that this Proposal shall be the basis of any insurance issued. 1. NAME OF FIRM : 2. COMPANY NO.: 3. Goods and Services Tax (GST) Related Questions: a) Are you registered for GST? Yes No b) If Yes, please provide: (i) GST Registration Date: - - (DD MM YYYY) (ii) GST Registration No: c) If you are a Business Entity, are you a Sole Proprietor? Yes No d) If Yes, is the subject matter insured for Business Non Business Both 4. Full name of all entities to be insured (including service, administrative or nominee companies and subsidiaries that you wish to be covered by this Policy): 5. Address of FIRM: 6. Address (es) of branch offices or other locations. 7. When was the Firm established: / / 8. Management and Personnel Details Please supply the following details. Names of Partners, Principals and Directors Age Qualifications Date Qualified Period Practicing as Partner, Principal or Director This Practice Previous Practices 1

2 Please supply total numbers of: (i) Partners/Principals/Directors (ii) Qualified Staff (iii) Other technical staff (iv) Trainee staff (v) Non-technical administrative staff (vi) Clerical staff (vii)other staff (please specify) TOTAL (All Staff) FOR SOLE PROPRIETORS ONLY QUESTIONS (c) AND (d) (c) State the experience of assistants and their length of service. (d) What arrangements are in place to assist during temporary absence of sole proprietor on business, leave or sickness, or unforeseen emergency? 9. Details of Practice Has the name of the practice ever been changed? Has there been other practice or business amalgamation or merger with you? (c) Has any other practice or business been purchased? If the answer is Yes to either part,, or (c), please supply details. (d) Is any Partner, Principal or Director connected or associated (financially or otherwise) with any other practice or business? If the answered is Yes please supply details. (e) Please list the professional bodies or associations to which the Firm belong to. (f) Please detail the approximate percentage of fee income derived from the following fields of work: Type of Work Type of Work Estate agency (general practice) % (f) Loss assessment/adjustment % Valuation % (g) Insurance agency/financial institutions agency % (c) Auctioneering % (h) Property conveyancing / % settlement agency / land broking (d) Rent collection % (i) Project management % (e) Strata title/property management % (j) Other (please specify) % TOTAL 100% 2

3 (g) Please detail the approximate percentage of total work in the following areas: Domestic property % (d) Hotel/licensed premises % Industrial/Commercial property % (e) Plant/machinery % (c) Rural property % (f) Other (Please specify) % TOTAL 100% (h) Does the Firm undertake valuations? If yes, (i) Please detail the approximate percentage of fee income FOR VALUATION WORK derived from the following areas: Domestic property % (e) Plant/machinery % Industrial/Commercial property % (e) Domestic finance company briefs % (c)rural property % (f) Municipal valuations % (c)hotel/licensed premises % (f) Other (Please specify) % TOTAL 100% (ii) Are valuations only undertaken by professionally qualified and/or licensed valuers? If No, please supply details. (i) Does the Firm provide strata title management? If Yes, please provide the following details. the approximate number of blocks managed during the last 12 months [ ] the approximate number of units managed during the last 12 months [ ] (j) Complete if applicable (refer Question g above) state the number of agencies with binding authorities [ ] state the number of agencies without binding authorities [ ] (c) state the percentage of total premium written for the following classes of insurance: (i) Property or business packages [ % ] (ii) Liability [ % ] (iii) Others (please specify) [ % ] (k) Please provide brief description, location, type and fees for the five (5) largest contracts undertaken over the past five (5) years. BRIEF DESCRPTION LOCATION TYPE (INDUSTRIAL/COMMERICAL VALUATION ETC) FEES (l) Does any contract or client represent more than 50% of annual work or fees? 3

4 (m) Does the Firm engage consultants, sub-contractors or agents (other than real estate agents)? If Yes Does the Firm insist that they carry their own Professional Indemnity Insurance? Does the Firm enter into any hold-harmless agreements or otherwise waive any legal rights or entitlements which may have against such consultants, sub-contractors or agents? (n) Does the Firm envisage any substantial changes in activities or are there any major new operations contemplated during the next 12 months? (o) Are verbal reports always confirmed in writing? If No, how does the Firm substantiate such verbal reports: (p) Does the Firm perform work outside of Singapore, or work for clients located Overseas? 10. Financial Position of the Corporation Please advise the date of Firm s financial year end: /../.. Please provide the amount of gross income/fees for the following: Malaysia Other (i) Current financial year (estimate) (ii) Last financial year (iii) Previous financial year (c) Please provide the amount of the largest annual fee for any one client. (d) Please provide the approximate percentage of Firms activities (based on fee income) applicable to each country from which a portion of Firms income is derived.. Country MALAYSIA ASIA EUROPE USA/CANADA OTHER Percentage of Income % % % % % 11. Claims Details Has any Partner, Principal, Director or staff member ever been subject to disciplinary proceedings for professional misconduct? 4

5 Have any claims for negligence or breach of professional duty been made in the last ten (10) years against the Practice or any of the Firm s predecessors in business or any prior Practice of any of their present or former Partners, Principals or Directors, or have circumstances been notified to insurers that might give rise to a claim? If yes, please provide the following details in respect of each matter. Date Matter Notified Name of Insurer (if any) Name of Claimant or potential Claimant Brief description of the Matter Amount Paid or Estimate of Potential Liability Is Matter Finalised or Outstanding? (c) Are any of the Partners, Principals or Directors, AFTER ENQUIRY, aware of any claim or circumstances that might give rise to a claim against the Practice or any prior Practice or any of their present or former Partners, Principals or Directors which is not referred to in question above? If yes, please provide the following details in respect to each matter. Name of Claimant or potential Claimant Brief description of the Matter Estimate of Potential Liability 12. Insurance Cover Does the Practice presently carry, or has the Practice ever carried, Professional Indemnity Insurance? Insurer: Expiry Date Limit of Indemnity Premium Has the Practice or any Partner, Principal or Director ever been refused for this type of insurance, or had similar insurance been cancelled, or had an application of renewal declined, or had special terms been imposed? 13. Application for Cover Limit of Indemnity required: Deductible/Excess requested: (Each and Every Claim) Option 2 Limit of Indemnity required: Deductible/Excess requested: (Each and Every Claim) Option 3 (c) Limit of Indemnity required: 5

6 (d) Deductible/Excess requested: (Each and Every Claim) 14. Extension of Cover a) Is cover required for Partners previous Business If the answer is Yes please supply details Name of Partner Title of Previous Business Dates of Previous Business b) Please indicate if the following covers are required. (i) Loss Of Documents If Yes, does the FIRM keep documents in fireproof cabinets? (ii) Libel and Slander (iii) Dishonesty of Employees (iv) Outgoing Partners If the answer is Yes please supply details Name of Partner Date Left Practice Declaration I/We the declare that the statements and particulars in this proposal are true and that I/We have not misstated or suppressed any material fats. I/We agree that this proposal, together with any other information supplied by me/us shall form the basis of any contract of insurance effected thereon. I/We undertake to inform insurers of any material alteration to these facts whether occurring before or after completion of the contract of insurance. Date: Signature of Practice: For and on behalf of: (Insert name of Firm) Goods and Services Tax Notice You are advised to review the adequacy of your Sum Insured as Goods and Services Tax ( GST ) may have an impact on your claims settlement as stated below. Goods and Services Tax Impact on Claims Settlement Claims Settlement We will indemnify you on claims made by third party inclusive of the GST, up to the Limit of Indemnity. In the event that you are entitled to claim for the Input Tax Credit and if we make a payment under this policy as compensation to you, we will reduce the amount of the payment by deducting your Input Tax Credit entitlement irrespective of whether you have or have not claimed the Input Tax Credit, up to the Limit of Indemnity. 6

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