Scribd
Upload
236 views

CGL Application Form - Corporate (Final)

This document is an application for comprehensive general liability insurance submitted by IDC Automation & Industrial Services. It provides details about the applicant such as business address, nature of business as a contracting service, and authorized representative. It also requests underwriting details about the business premises, insurance coverage amounts, and loss history. Finally, it contains statements for the applicant to authorize the collection and use of personal data in accordance with privacy laws.

Uploaded by

Jan Garcia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
236 views

CGL Application Form - Corporate (Final)

This document is an application for comprehensive general liability insurance submitted by IDC Automation & Industrial Services. It provides details about the applicant such as business address, nature of business as a contracting service, and authorized representative. It also requests underwriting details about the business premises, insurance coverage amounts, and loss history. Finally, it contains statements for the applicant to authorize the collection and use of personal data in accordance with privacy laws.

Uploaded by

Jan Garcia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

COMPREHENSIVE GENERAL LIABILITY APPLICATION FORM – CORPORATE CLIENT

Client information as mandated under the Phil. Anti-Money Laundering Act (AMLA) R.A No.10365 as
amended. Complete information is required before a policy is issued.

Business/Company Name:
IDC Automation & Industrial Services
Business/Company Address: Contact No.:
Blk 24 Lot 22, Zeus St., Phase 3, North Olympus Subd., 09399182683
Kaligayahan, Novaliches, E-mail Address:
Quezon City [email protected]
Nature of Business: TIN:
Contracting Service 105-967-835-000
Date of Incorporation Place of Registration
N/A (Sole Proprietorship)
List of Directors/Partners: List of Principal Stockholders Owning at least 2%
Ibarra D. Concepcion Jr. of capital stock (or attach the latest General
Jan Emmanuel C. Garcia Information Sheet):

Beneficial Owners, if any: (First Name, Middle Name, Surname)

Name of Authorized Representative: Position: Contact No.:


(First Name, Middle Name, Surname)
Jan Emmanuel Camposano Garcia Admin & Ops Mngr 09399182683

Form completed by: Position: Date:


Jan Emmanuel Camposano Garcia Admin & Ops Mngr March 8, 2023

Please attach Articles of Incorporation/Partnership and By-Laws


UNDERWRITING DETAILS
Business Name:
Philip Morris Inc.
Location of Premises to be covered:

Nature of Operation undertaken on the Premises:


☐ Office ☐ Warehouse ☐ Hotel ☐ Resort ☐ Restaurant ☐ Factory
☐ Motor Shop ☐ Spa ☐ Salon ☐ Retail Store ☐ Others, please specify_________________
Total Floor Area (in square meters) Amount of Insurance Requested
$1M USD
Do you want to extend coverage beyond general public liability for the following exposure?
Automobile Liability ☐ Yes ☐ No If yes, please provide total number of vehicles
owned/leased/maintained_________
Broad Water Damage ☐ Yes ☐ No
Car Park Liability ☐ Yes ☐ No If yes, please provide total number of parking slots________
Cross Liability ☐ Yes ☐ No If yes, please provide name of co-insured_________
Employer’s Liability ☐ Yes ☐ No If yes, please provide total number of employees_________
Fire & Explosion Liability ☐ Yes ☐ No
Fire Legal Liability ☐ Yes ☐ No
Food & Drink Liability ☐ Yes ☐ No If yes, please provide total number of seating capacity________
Garage Keeper’s Liability ☐ Yes ☐ No If yes, please provide total number of parking slot________
Innkeeper’s Liability ☐ Yes ☐ No If yes, please provide total number of room_________
Premises Medical Payments ☐ Yes ☐ No
72 Hours Sudden & Accidental ☐ Yes ☐ No
Pollution
Tenant’s Legal Liability ☐ Yes ☐ No
Valet Parking Liability ☐ Yes ☐ No If yes, please provide total number of valet parking slots_______

Valet Drivers :
Name Age
License #
1. ___________________ _______ ______________
2. ___________________ _______ ______________
3. ___________________ _______ ______________

Loss History
Have you had any losses, claims or incidents during the last 5 years? ☐ Yes ☐ No
If yes, please provide details_______________________________________________

Has any Insurer canceled, declined, or refused to renew any liability insurance policy? ☐ Yes ☐ No
If yes, please provide details_______________________________________________

Do you have an existing agent with ABIC? ☐ None ☐ Yes Agent’s Name:______________
Note: This Application, if approved, shall form part of and shall be the sole basis in issuing the Comprehensive General
Liability 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.

Data Privacy. Pursuant to the foregoing Application, by signing and returning this application form, I consent to the
collection, use, recording, storing, organizing, consolidation, updating, disclosure, sharing and/or general processing and
transfer of my personal data as described in this paragraph and in accordance with the Data Privacy Act of 2012 (R.A. 10173).
I understand that the Company and/or its related companies hold certain personal information and sensitive personal
information about me (including but not limited to my name, address and telephone number, date of birth, social security
number, tax identification number, etc.) for purposes directly or indirectly relevant to processing my Insurance Cover. I also
understand that my personal and sensitive personal information may also be used by the Companies’ administration and
management of applicant. I understand that The Company may transfer this Personal Data amongst its related companies
as necessary for the purpose of processing, administering and managing my Insurance Cover, and that the Company may
also transfer this Data to any third party assisting the Company in the processing, administration and management of my
insurance. I authorize them to receive, possess, use, retain and transfer the Data, in electronic or other form, for these
purposes. I also understand that I may, at any time, review the Data, require any necessary changes to the Data or withdraw
my consent in writing by contacting the Company. The permission that I’m granting the Companies shall be effective
immediately and shall continue as long as necessary for the Companies to use this Data for the purpose of my Insurance
Cover and for the compliance of applicable laws and regulations, unless I inform the Company in writing of my decision to
revoke my permission for them to use my Data, in which case, the Companies shall immediately cease from collecting using,
recording, storing, organizing, consolidating, updating, disclosing, transferring, sharing and/or general processing of my
Personal Data. I further understand that withdrawing my consent may substantially affect my ability to further process and
collect on my insurance. The full ABIC Privacy Policy can be found at www.alliedbankers.com.ph

“I hereby authorize ABIC to inquire about and investigate all the declared information from whatever sources ABIC
may consider appropriate and use any contact details to communicate to me for whatever purpose (such as
customer satisfaction surveys, etc.).”

March 8, 2023
Signature of Applicant Date

You might also like