Allianz General Insurance Company (Malaysia) Berhad (735426-V)

PUBLIC LIABILITY EVENT INSURANCE

PROPOSAL FORM
Allianz General Insurance Company (Malaysia) Berhad is licensed under Financial Services Act 2013 (FSA) and regulated by Bank Negara
Malaysia (BNM).
Account No:

STATEMENT PURSUANT TO SECTION 149(4) OF THE INSURANCE ACT 1996 -You are to disclose in this proposal form, fully and faithfully all the facts
which you know or ought to know, otherwise the policy issued hereunder may be invalidated.
Policy No:
IMPORTANT NOTICE TO PROSPECTIVE POLICY OWNERS
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. Cover Note No:
The liability of the Company does not commence until acceptance of the proposal has been intimated by the Company or official
cover note is issued.

ALL QUESTIONS MUST BE ANSWERED BY THE PROPOSER AND APPROPRIATELY MARKED ' √ ' WHERE APPLICABLE.

COMPANY DATA

Name of Proposer :

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Business, Trade or Occupation of Proposer : ___________________________________________________________________

Company No. : ___________________________________________________________________________________________

Correspondence Address :__________________________________________________________________________________

_______________________________________________________________________________________________________

Telephone No. (O): _______________________________(H /P): __________________________________________________

Email : _________________________________________Fax No. : _________________________________________________

Organiser of the Event :

(if different from the Name of Proposer)

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Company No. : ___________________________________________________________________________________________

Correspondence Address : _________________________________________________________________________________

_______________________________________________________________________________________________________

Telephone No. (O): _________________________________(H/P): ________________________________________________

Email: ____________________________________________Fax No.: ______________________________________________

Head Office: Suite 3A-15, Level 15, Block 3A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur. Tel : 03-2264 1188 / 03-2264 0688
Fax : 03-2264 _________________________________________________________________________________________
1199 www.allianz.com.my
______________________
Customer Service: Ground Floor, Block 2A, Plaza Sentral, Jalan Stesen Sentral 5, Kuala Lumpur Sentral, 50470 Kuala Lumpur. Tel: 03-2264 0700 Fax: 03-2264 0602
Toll Free : 1-300-88-1028 customer.service@allianz.com.my
Tel No. _________________________________________ Hand phone AZ 05/14
._______________________________________________

Email ___________________________________________ Fax No.

______________________________________________________
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Allianz General Insurance Company (Malaysia) Berhad (735426-V)

GENERAL INFORMATION ABOUT THE EVENT

1.1 Type of Event:

1.2 Name/Specification of the Event :

1.3 Venue of the Event :

_________________________________________________________________________________________________
(Please enclose separate tour itinerary in the case of a series of events/tour)

1.4 Date of the Event :

Commence : _________________________________Finish: _______________________________________________

1.5 Period of Insurance :

Finis______________________________________________________________________________
From : _______________________________________To:___________________________________________________
_______
1.6 Has a similar event been held before?

Yes No

If Yes, please give details: _____________________________________________________________________

1.6.1 Was the event Insured?

Yes No
Place, Date etc.)
____________________________________________________________________________
If Yes, please state the name of the Insurance Company: ___________________________________________________
_______________________________________________________________________________

1.6.2 Was a loss suffered?

Yes No

If Yes, please specify nature of loss and loss amount : __________________________________________________

1.6.3 ____________________________________________________________________________
Are you aware of any circumstances which is likely to give rise to a claim?
___
Yes No
____________________________________________________________________________
_____________
If Yes, please give details :_____________________________________________________________________________

____________________________________________________________________________________
1.7 Estimated number_of people per day / or per event / show :

____________________________________________________________________________
1.8 Has the insurance now proposed been declined, cancelled, refused renewal or subjected to any special terms by any other
_____________
Insurance Company?

Yes No

If Yes, please give details : ___________________________________________________________________________

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Allianz General Insurance Company (Malaysia) Berhad (735426-V)

1.9 What Limit of Indemnity is required ?

1.10 Are fireworks/pyrotechnics displayed or used during the event?

Yes No

If Yes, please give details:_____________________________________________________________________________

1.11 Have all the necessary licences and permits been obtained from all relevant authorities?

Yes No

If No, please give details:_____________________________________________________________________________

1.12 What are the security arrangements in place at the venue? Please provide details of the following in respect of the venue :-

a) Fire fighting facilities:________________________________________________________________________

b) Number of police or RELA Team to control the crowd: ______________________________________________
c) First Aid Safety facilities: ______________________________________________________________________

DECLARATION

I/We to the best of my/our knowledge hereby confirm that the statements contained in this proposal form are true and correct and
I/We have not concealed, mis-represented or mis-stated any material facts.

I/We agree that this statements and declaration contained in this proposal form shall be the basis of the contract of insurance with
the Company and are deemed to be incorporated in the contract.

__________________________ _________________________________
Date Signature of Proposer/Company’s Chop

IMPORTANT NOTICE
Please note that all policies, cover note and endorsement issued would require the premium to be paid in full prior to inception of
risk (Cash Before Cover).

DECLARATION ON THE VERIFICATION OF AN INSURED IN COMPLIANCE WITH SECTION 16(2) OF THE ANTI-
__________________
MONEY LAUNDERING ACT 2001
I_____________________________bearing NRIC number__________________________________an *employee/agent of Allianz
General Insurance Company (Malaysia) Berhad hereby certify that the Proposer’s original NRIC/Business Registration Certification for
____________________________________was verified and authenticated by me at the point of sales. I further confirm that the
relevant documents were sighted and verified and the insured is not suspected of money laundering or financing of terrorism.

Signature:___________________________________ Date:____________________________________*Delete where appropriate.

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