OSCAR Proposal Form

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.

Section I. Proposer Details

1. Company Name

2. Address

3. Detailed Scope of work performed

4. No. of years you have been engaged in this type of work

5. Duration of Contract: ________________ months

Maintenance Period: ________________ months

6. Name of the Principal(s) for whom you are performing work for

7. Location of Work ________________________________

(i) Onshore Yes No

(ii) Offshore Yes No

If your business involves offshore works, please answer a) - d) below.

a) Name and/or number of *mobile rig/ platform/ vessel

* Please delete where appropriate.
b) Location/ Distance Offshore

c) Means of Crew Transport to/from By Air By Sea

d) Rotational Time-table (Days on/off) _________ On/ _________ Off

 8. Employee Data\
Please provide gross payroll including bonus, overtime, allowances and value of food, housing and services.

Classification Malaysian Asean Aust/UK USA Others

Total Payroll

Total number of employees

Maximum number of employees
on site at any one time.
Maximum number of employees in
one mean of conveyance at any
one time.
Rotational timetable .
Number of working days
Number of off day

9. Contract Value (RM)

Section II. Loss Information

Please tick the applicable box. YES NO

1. Has the company experienced any terrorism related threats or incidents before?

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.

5. Do you have any domiciled operations or exposures in Myanmar?

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.

Workers Compensation Benefits Number of employees

Voluntary Malaysian Benefits
Others. Please specify. ________________

2. Employers Liability
Limit of Liability: ______________________ per occurrence and in the aggregate

3. Comprehensive General Liability

Limit of Liability Requested: _________________

4. Territory: __ Malaysia only

__ ASEAN

5. Jurisdiction: __ Malaysia only

__ ASEAN

Section IV. Declaration

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.

Proposer Signature & Co. stamp: _______________________ Date:______________________

Proposer Name & Title : ________________________

Broker/Agent : _______________________

Contact number & e-mail address : _______________________

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

I I hereby declare that sighted the original NRIC of the proposers

authorised signatory / Business Registration Certification of the
proposer and thereby verify his/her/its identity.
Saya dengan in mengesahkan bahawa saya telah meneliti Kad
Pengenalan wakil pemohon/ Sijil Pendaftaran Perniagaan asal
pencadang dan dengan itu, mengesahkan identiti beliau.

Signature (Agent/Officer)
Tandatangan (Ejen/Pengawai)

Name / Nama : .

Date / Tarikh : ..

Jan 2012