Financial Questionnaire For Business Insurance

Transcription

1 HSBC Insurance (Singapore) Pte. Limited. (Reg. No N) 21 Collyer Quay #02-01 Singapore , Monday to Friday 9.30am to 5pm Customer Care Hotline: (65) Fax: (65) Mailing address: Robinson Road Post Office P.O. BOX 1538 Singapore Financial Questionnaire For Business Insurance WARNING: STATEMENT PURSUANT TO SECTION 25(5) OF THE INSURANCE ACT, YOU ARE TO DISCLOSE IN THIS FORM FULLY AND FAITHFULLY, ALL THE FACTS WHICH YOU OUGHT TO KNOW, OTHERWISE THE REQUEST EFFECTED HEREUNDER MAY BE VOID. Proposal No. : Name of Life Insured : Name of Policyowner : Please indicate the purpose of insurance. Please tick whichever is applicable. a. Key Person Protection (Please complete Section A, B and E) b. Business Loan Protection (Please complete Section A, C and E) c. Partnership or Shareholder Protection including Buy/Sell (Please complete Section A, D and E) Section A 1. a. Name of company: b. Nature of business: c. Registered address: d. Number of years that the company has been in business: e. Number of employees: f. Number of years you are being employed by the company: 2. Please state the turnover and net profit before tax for the last 3 years. Turnover Year: Year: Year: Gross profit Net profit before tax Page 1 of 6

2 3. Please provide details of officers or principals who hold executive authority of the company: Please provide details of officers or principals of the corporations, whose instructions and signatures are empowered to act and give instructions: Signature Signature: Signature: Signature: Page 2 of 6

3 Section B: For Key Person Protection 1. How do you as a key person contribute to the profit of the company? (To include description of your role, your duties, specialized skills, qualifications or experience and other relevant details.) 2. How was the proposed sum insured and the benefit and/or loss to the firm calculated? 3. Please state total remuneration received in the last 3 years: Year : Year: Year: 4. What is the proportion (in percentage) of net profit that can be fairly attributable to you? 5. Are any other persons in the business considered as key persons? Yes No Name of Keyperson(s) Designation Insured with key person policies? (Yes / No) If Yes, please state the total sum insured. If No, please provide reason. 6. Does your company have any current pending or existing business Yes No insurance proposals being made on your life to other insurance company? Company Type of cover and sum insured Purpose of cover Commencement date Life TPD CI 7. Do you have ownership interest or shareholding in the business? Yes No If Yes, please provide percentage of shares and the current value of this interest or shareholding. Page 3 of 6

4 Section C: Business Loan Protection 1. Please provide details of the loan that you wish to protect a. Purpose of loan: b. Name of lender(s): c. Loan amount and tenure: d. Your percentage of ownership (if any) in the entity: e. Percentage of loan that you are responsible for: 2. Are there any other borrowers? Yes No Name of other borrowers Insured with business loan policy? (Please indicate: Yes /No) If Yes, please indicate details of the policy such as sum insured, benefits and policy commencement date. Page 4 of 6

5 Section D: Partnership or Shareholder Protection including Buy/Sell 1. Please state your percentage of ownership in the entity. 2. What is the current value of the business? 3. How and when was this value calculated? 4. What is the value of your interest in the business? 5. Is a partnership, shareholder or buy/sell agreement in place? Yes No If Yes, please provide details. 6. How many partners/shareholders are there in the business? 7. Please indicate the ownership or percentage which the partners /shareholders own. 8. Is insurance cover being proposed or already in-force on other business Yes No owners? Name of partner(s) or shareholders Details of insurance being applied or in-forced (such as sum insured, term, benefit) 9. How was the sum insured proposed calculated? Page 5 of 6

6 Note: The following documents must be submitted together with the proposal form: (i) (ii) (iii) (iv) (v) A certified copy of the Certificate of Incorporation, Certificate of Partnership or Certificate of Registration, Memorandum & Articles of Association A copy of most recent ROC (within 1 year) Identification documents of 2 directors or partners Identification documents of all authorized signatory(ies) Proof of address of all authorized signatory(ies) I declare that to the best of my knowledge and belief, the information given by me is true and complete and that no material facts (i.e. facts likely to influence the assessment and acceptance of my proposal for the life insurance) have been withheld. I agree that this form shall constitute a part of my proposal for Life Insurance with HSBC Insurance (Singapore) Pte. Limited. Signature of Life Insured Name Signature of Policyowner * Name & Designation of Signatory Company name and stamp Date Please note that the person signing off as policyowner should be the authorised signatory of the company. Page 6 of 6