F-S&U-47
Revision No. 01
June 1, 2016
FIRE INSURANCE 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.
☐ Residential ☐ Warehouse
☐ Commercial ☐ Industrial
Business/Company Name:
Business/Company Address: Contact No.:
E-mail Address:
Nature of Business: TIN:
Date of Incorporation: Place of Registration:
List of Directors/Partners: List of Principal Stockholders Owning at least 2% of capital
stock (or attach the latest General Information Sheet):
Beneficial Owners, if any:
Name of Authorized Representative: Position: Contact No.:
Form completed by: Position: Date:
Please attach Articles of Incorporation/Partnership and By-Laws
F-S&U-47
Revision No. 01
June 1, 2016
UNDERWRITING DETAILS
BUILDING
Address of Property to be Insured
Description of Building
Nearest Landmark
Properties to be Insured
Amount of Insurance Applied for No. of detached buildings
Age of Building Basement
No. of storeys/floors Total Ground Floor Area
The Property is Occupied as
☐ Residential ☐ Warehouse
☐ Commercial ☐ Industrial
*For properties occupied as commercial and industrial, please indicate nature of business. For warehouse, indicate the type
of goods in storage ____________________________________________________________________________
The roof is made of? The exterior walls are made of?
☐ GI Sheet ☐ Reinforced Concrete ☐ Concrete/Concrete Hollow Blocks
☐ Tegula ☐ Others (please specify) ☐ Concrete/Concrete Hollow Blocks with Timber
__________________ ☐ Others (please specify)
_______________________________________
Boundaries (Houses, Buildings or Street surrounding the property)
Occupancy No. of Storeys Roof Exterior Walls
Front ____________________ _______________________ _____________________ _______________________
Right ____________________ _______________________ _____________________ _______________________
Left ____________________ _______________________ _____________________ _______________________
Rear ____________________ _______________________ _____________________ _______________________
CONTENTS
Description
☐ Furnitures, Fixtures, Fitting Amount:______________
:_______________________________________
Description
☐ Leasehold Improvement / FFFE Amount:______________
:_______________________________________
Description
☐ Machinery / Equipment Amount:______________
:_______________________________________
Description
☐ Stocks Amount:______________
:_______________________________________
Description
☐ Others (Please Specify) Amount:______________
:_______________________________________
Desired Coverage
☐ Fire & Lightning ☐Typhoon ☐ Extended Coverage
☐ Earthquake ☐Flood ☐ Riot, Strike, Malicious damage
☐ Robbery & Burglary ☐ Others (please specify)
With Grills _____ Yes _____ No _____________________________
_____________________________
With Security Guards _____ Yes _____ No
_____________________________
F-S&U-47
Revision No. 01
June 1, 2016
With Perimeter Fence _____ Yes _____ No _____________________________
Height of Perimeter Fence _________________________
Is the property mortgaged? Interest on the property
☐ No ☐ Owner ☐ Lessee ☐ Part Owner
☐ Yes, Mortgagee:____________________________ ☐ Mortgagor ☐ Contractor ☐ Others (Please specify)
_________________
Have you had a fire loss or any other losses (e.g. earthquake, typhoon, flood, etc.) in this or other premises?
Past 3 years ☐ Yes ☐ No
Past 5 years ☐ Yes ☐ No
Date of Loss : ___________________ Nature of Loss/Extent: __________________________
Amount of Loss/Received: ______________________________________________________________________
Address of Property: ______________________________________________________________________
Insurance Company: ______________________________________________________________________
SPECIAL HAZARDS: (For Commercial, Warehouse & Industrial Occupancies)
None ☐ Yes ☐ No Explosive Dusts: ☐ Yes ☐ No
Ovens, Furnaces, Heaters: ☐ Yes ☐ No Radio Active Materials ☐ Yes ☐ No
Flammable Solvents: ☐ Yes ☐ No Smoking Control ☐ Yes ☐ No
Flammable Gases: ☐ Yes ☐ No Cutting & Welding ☐ Yes ☐ No
Others: __________________________________________________________________________________________
Storage Arrangement: (For Warehouse Occupancy)
Separate from production areas ☐ Yes ☐ No
Maximum storage height: ____________________________________________________________________________
UTILITIES
Fuel: ☐ LPG ☐ Coal ☐ Electric
Electricity:
Distributor ________________________________________________________________________
Generator ☐ Yes ☐ No Capacity: ______________________________________
Boilers: ☐ Hot Water ☐ Steam
BUSINESS INTERRUPTION
Plant operates _________________________Shifts __________days per week No. of Employees ______________
Production bottleneck ☐ Yes ☐ No Where______________ Alternate production facilities ☐ Yes ☐ No
Stock of raw materials _____________________________weeks Stock of finished products ______________ weeks
Availability of raw materials ______________________________ Critical utilities ____________________________
Replacement time of machinery ____________________months Replacement time of building __________ months
PROTECTION
Automatic sprinklers ☐ Yes ☐ No Hand extinguisher ☐ Yes ☐ No
Inside hose reels ☐ Yes ☐ No Yard hydrants ☐ Yes ☐ No
Water supply to automatic sprinklers, inside hose reels and yard hydrants
Private ☐ Yes ☐ No Watchman service ☐ Yes ☐ No
Public ☐ Yes ☐ No Fire detection system ☐ Yes ☐ No
Private fire brigade ☐ Yes ☐ No
PUBLIC FIRE DEPT. ____________________ Distance__________________________
F-S&U-47
Revision No. 01
June 1, 2016
(FOR UNDERWRITING USE ONLY)
Location Code: ___________________________
District No./Name: ___________________________
Block No.: ___________________________
Risk No.: ___________________________
Earthquake Zone: ___________________________
Do you have an existing agent with BPI/MS? ☐ None ☐ Yes Agent’s Name:_________________
Note: This Application, if approved, shall form part of and shall be the sole basis in issuing the Fire 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.
“I hereby authorize BPI/MS to inquire about and investigate all the declared information from whatever sources BPI/MS
may consider appropriate and use any contact details to communicate to me for whatever purpose (such as customer
satisfaction surveys, etc.).”
Signature of Applicant Date
Financial product/s of BPI/MS is/are not insured by the Philippine Deposit Insurance Corporation and
is/are not guaranteed by the Bank of the Philippine Islands.
PAYMENT OPTIONS
☐ Cash ☐ BPI Debit Card ☐ BPI Express Online ☐ Credit Card
Please refer to the Payment Facilities page for more details.
To be accomplished by BPI personnel
F-S&U-47
Revision No. 01
June 1, 2016
TRACKING FORM
Client’s RM No.:
Referrer’s name:
Referrer’s Employee No.:
Referring Branch code:
Referring Branch name:
Dealer’s name:
