NOTICE: Pursuant to Section 150 of the Insurance Act, 1996 of Malaysia, 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 void.
Coverages requested in this proposal form are not to be construed as an acceptance or commitment on
the part of the insurer unless the same is incorporated in the Policy/ Cover Note evidencing such cover.
1. Company Name
2. Address
6. Name of the Principal(s) for whom you are performing work for
Total Payroll
2. Do you have any assets in the U.S. or is there an ownership interest in your company
by any US entity?
3. Has any insurer cancelled or non-renewed any of the companys insurance cover in the
past 5 years?
4. Has the company had any prior losses either insured or uninsured involving injury to
your employees and/or third parties in the past 5 years? If yes, please provide full details.
Were you previously insured for these types of insurance covers for other contracts awarded to you?
Yes/No.
If yes, please state the insurer(s) that you purchased such insurance covers from.
For WC/EL: _____________ GL: ________________
Section III. Limits Requested
1. In the employment contracts, are country of origin benefits provided? _______
If yes, please specify number of employees.
2. Employers Liability
Limit of Liability: ______________________ per occurrence and in the aggregate
I/We declare that the statements and particulars inserted in this proposal form are true and accurate and
that no material facts have been suppressed or mis-stated. I agree that this proposal, together with any
other information supplied shall form the basis of any contract of insurance effected thereon. I undertake
to inform AIG Malaysia Insurance Berhad (795492-W) about any material alteration to those facts
occurring before completion of the contract of insurance.
Broker/Agent : _______________________
Note: No liability is undertaken until this Proposal Form has been accepted and premium paid in full.
IMPORTANT NOTE: In order for us to understand your operations better, please provide us extracts from your
contract, relating to Scope of Work, Responsibilities/Indemnities and Insurance.
Declaration by Agent/Officer
Pengisytiharan oleh Ejen/Pengawai
Signature (Agent/Officer)
Tandatangan (Ejen/Pengawai)
Name / Nama : .
Date / Tarikh : ..
Jan 2012