Compas Office Insurance Application Form
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1COMPAS OFFICE INSURANCE
Please list below any item of office machinery included in the sum insured
INSURANCE HISTORY
____
__
above where the value exceed HK$100,000.
1. In respect of the Insurance you now propose, have you ever made any
APPLICATION FORM
claims against any insurer for this or any other premises owned or
Description
Value (HK$)
occupied by you during the past three years?
COMPANY DATA
□ Yes
□ No
(please provide information in English and block letters)
2. Has any company or insurer ever declined to insured you or your
Name of Applicant :_________________________________________________
property imposed special terms or cancelled or refused to renew your
insurance ?
Nature of Business :_________________________________________________
□ Yes
□ No
Postal Address : ____________________________________________________
If “Yes” to any of the above questions, please give details :
_________________________________________________________________
__________________________________________________________
Public Liability (Free Cover)
Address of Insured Premises : _______________________________________
IMPORTANT NOTE
Limit of Indemnity up to HKD5,000,000.
Any other facts known to you which are likely to affect acceptance of assessment of the
_________________________________________________________________
insurance cover you are requesting must be disclosed. Should you have any doubt about what
you should disclose, do not hesitate to ask us or your insurance intermediary. We recommend
Loss of Money (Free Cover)
you keep a record (including copy of this application) for your future reference of any additional
Telephone : ______________________ Fax : ____________________________
information given. Providing correct answers and making sure we are informed is for your own
As stated in this brochure
protection, as failure to disclose such information may mean that your policy will not provide
E-mail : __________________________________________________________
you with the cover you require and may even invalidate the policy altogether. Please note that
this application will not become effective until this proposal has been accepted by the Company.
Business Interruption (Free Cover)
Contact Person : ___________________________________________________
Additional Expenditure up to HK$500,000.
DECLARATION
__________
We hereby declare that the particulars and statements given above are, to the best of my/our
Period of Insurance : From ________________________________________
OPTIONAL COVER
knowledge and belief, true and complete. We agree that this proposal shall be the basis of the
contract between themselves and GAN Assurances (“the Company”). We understand and agree
(Day/Month/Year)
To
_________________________________________
that the information collected is to enable the Company to carry on business and may be used for
Employees’ Compensation
the purpose of any insurance or financial related product or service or any alterations, variations,
cancellation or renewal of them; any claim or analysis of it; and may be transferred to any related
Occupation
No. of
Est. Annual
company or any other company carrying on insurance or reinsurance related business or an
BASIC COVERS
intermediary or a claims or investigation or other service provider providing services relevant to
Employees
Earnings
insurance business or any association or federation of insurance companies that exists or is
1. Admin./Clerical Staff
formed from time to time. We understand that We have the right to obtain access to and to
request correction of any personal information concerning ourselves held by the Company.
2. Salesman
Request for such access can be made to the Company’s Data Protection Officer.
Office Contents “All Risks”
3. Messenger/Amah
4. Private Car Driver
Total Sum Insured (HK$)
______________________________________
_______________________________
Applicant’s Signature
Date
5. Others (please describe)
Authorised Agent/Broker
N.B. : (The sums insured must represent the full cost of replacement of the
property with an allowance for inflation and future additions)
Please fill in this Application form and mail it or fax it to us
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Parent category: Business