22/F Pacific Star Building, Sen. Gil Puyat Ave.

, Makati City

MALL TENANTS INSURANCE PROGRAM (CARI)

Construction All Risk Insurance Application Form
(Coverage for Construction Works Within the Malls)

CONTRACTOR'S INFORMATION

Contractor’s Name: _______________________________________________________________________

Contact Person: __________________________________________________________________________
Office Title: __________________________________ Department: ________________________________
Mailing Address: _________________________________________________________________________
Direct/Trunkline: _____________________________ Fax # ______________________________________
Email Address: _______________________________ Mobile # ___________________________________
Policy Term: From _____________________________ To ________________________________________
TIN#_______________________________

TENANT'S INFORMATION

Store/Trade Name: _______________________________________________________________________

Registered Owner: _______________________________________________________________________
Contact Person: __________________________________________________________________________
Office Title: __________________________________ Department: ________________________________
Mailing Address: _________________________________________________________________________
Direct/Trunkline: _____________________________ Fax # ______________________________________
Email Address: _______________________________ Mobile # ___________________________________
Location at Mall: ______________________________ Mall Branch: _________________________________

Section I : MATERIAL DAMAGE

Amount Insured : _______________________ (Based on Contract Price)
Kindly provide a copy of ANY the following: Notice to Proceed (NTP), Purchase Order (P.O) Project Contract
(Note : If Contract Price is above P500,000, premium will be provided separately )

Section II : THIRD PARTY LIABILITY (TPL)

Amount Insured : Php 500,000.00

SCOPE OF WORK : ____ Installation/ Dismantling of Dropdown / Façade Banner

____ Construction of Store outlet
____ Renovation of Store outlet
____ Demolition of Store outlet
____ Others: ________________________________________

The above-presented program is supported by a set of top rate insurers that we have pre-screened among the various insurance companies in the country. Since
the tenants program is comparative to that of the insurance of SM PRIME HOLDINGS (common mall areas), these insurers were selected based on their
capacity, financial stability and service quality.

Conforme: ___________________________________

IMPORTANT: For issuance of Reference # and Insurance Policy,

please fax this form at 846-5941 / 846-5936 or contact the following:
LELIZA DIMAALA at 702-6000 local 57223, dimaala.leliza@bdo.com.ph
RITCHIE ROCA at 702-6000 local 57333, roca.richardedward@bdo.com.ph

This portion to be filled out by BDO Insurance Brokers Account Officer

Reference No:___________________________ Risk Code : Engineering (405)