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Business Information

Please make sure to answer honestly, with accurate and up-to-date information. If you don’t, your policy may be cancelled, and your insurer could reject your claim or declare not to pay it in full.

Company Name

Company Address

Postal Code

Revenue last 12 months (SGD)

Number of Employees

Industry

Ambulance/Medical Transportation Services

What services do you provide?

Description

Where do you transport patients to and from?

Please state some example countries where you will provide medical transportation services

Number of patients you transport per month, on average

Assisted living facilities/Nursing homes/Hospice

What is your maximum patient capacity

Do you provide medical services to your patients

What kinds of medical services do you provide?

Biomedical Engineering

Do you perform work in a laboratory?

Do you own or rent your laboratory?

Own
Rent

Do you perform hot work (e.g. work involving burners, heating elements, etc.)?

Chauffeur/Limousine Services

Do you transport clients by air or sea?

Please elaborate on how you transport clients by air or sea

Where do you transport clients?

Within Singapore only
Singapore and overseas

Please state the countries that you will transport clients to and from

How many clients do you transport per month, on average?

Under 50
51 to 100
100 to 200
Over 200

Please state the number of clients you’ll transport

Church

What is your maximum guest capacity?

How many events do you organise per year, on average?

What is the maximum attendance for any event?

What is the average attendance for an event?

Please provide examples of the largest events you’ve organised in the last 12 months

1	Event Name Event Description Maximum Number of Attendees
1	Event Name Event Description Maximum Number of Attendees

Add Row

Do you erect or dismantle scaffolds, e.g. for events?

Do you perform welding to erect or dismantle scaffolds?

Load premium

Do you perform, or organise events, involving any of the following?

Self-flagellation
Exorcism
Any other kind of activity that may result in physical injury

Buddhist / Taoist Temple

What is your maximum guest capacity?

How many events do you organise per year, on average?

What is the maximum attendance for any event?

What is the average attendance for an event?

Please provide examples of the largest events you’ve organised in the last 12 months

1	Event Name Event Description Maximum Number of Attendees
1	Event Name Event Description Maximum Number of Attendees

Add Row

Do you erect or dismantle scaffolds, e.g. for events?

Do you perform welding to erect or dismantle scaffolds?

Load premium

Hindu Temple / Sikh Temple

What is your maximum guest capacity?

How many events do you organise per year, on average?

What is the maximum attendance for any event?

What is the average attendance for an event?

Please provide examples of the largest events you’ve organised in the last 12 months

1	Event Name Event Description Maximum Number of Attendees
1	Event Name Event Description Maximum Number of Attendees

Add Row

Do you erect or dismantle scaffolds, e.g. for events?

Do you perform welding to erect or dismantle scaffolds?

Load premium

Do you perform, or organise events, involving any of the following?

Walking on hot coals
Body piercing
Any other kind of activity that may result in physical injury

Mosque

What is your maximum guest capacity?

How many events do you organise per year, on average?

What is the maximum attendance for any event?

What is the average attendance for an event?

Please provide examples of the largest events you’ve organised in the last 12 months

1	Event Name Event Description Maximum Number of Attendees
1	Event Name Event Description Maximum Number of Attendees

Add Row

Do you erect or dismantle scaffolds, e.g. for events?

Do you perform welding to erect or dismantle scaffolds?

Load premium

Do you perform, or organise events, involving any of the following?

Exorcism
Any other kind of activity that may result in physical injury

Hotel

What is your maximum guest capacity?

Do you have swimming pools in your hotel?

Are there lifeguards on duty in your swimming pool?

Do you provide valet parking services for your guests?

How many employees do you have?

Kayak tours

What's the average duration of each kayak tour (in hours)

What's the frequency of kayak tours conducted

What minimum qualifications (if any) do you enforce for kayak tour guides?

Can you confirm that all tour guides and participants must wear life vests while out on the water

Security Guard Service (Unarmed)

Building/Structural/Contractor Related Industries - Professional Indemnity

Does your Company:

Provide medical treatment or medical advice
Design buildings or structures
Audit publicly-listed companies
Give legal advice
Handle company insolvencies, liquidations, and receiverships
Value or survey assets
Operate digital aggregators (e.g. Uber for “X”)
Build payment gateways (e.g. Stripe)
Provide SCADA, cybersecurity, or IT security-related services
Need a licence issued by the Monetary Authority of Singapore
Provide services related to cryptocurrencies, digital currencies, or blockchain services
Provide services related to intellectual property including but not limited to trademarks, patents, and copyrights

Conditional Questions - Beazley Allied Healthcare Proposal Form

Please confirm if you and/or your sub-contractors/locum are licensed and/or qualified and/or accredited by the relevant professional bodies to perform the activities

Please provide details of any recognised qualification(s) held. Proof may be required by the underwriters:

Please confirm the number of treatments you performed for the discipline(s) that you require cover: (if applicable)

Previous year

Next year (estimate)

Please provide your total gross income based on your activity(ies) for which you require cover. If this is a new business please provide an estimated figure:

Previous year

Next year (estimate)

Please confirm if you require cover for past work
(retroactive cover)

If Yes, please confirm the date you have held continuous cover on a claim made basis

Which of the following services do you provide:

Cryptocurrency/crypto-related asset management (e.g. hedge fund investing in crypto assets)
Blockchain-related consulting (e.g. strategy or compliance advisory for blockchain companies)
Blockchain-related IT development (e.g. tech startup developing blockchain services)

What services does your Company offer?

Do you use subcontractors?

What percentage of your Company’s revenue comes from customers in the USA or Canada?

Has your Company ever

made a claim under a professional indemnity insurance policy before?
been sued by a customer for services provided to them?
been investigated by the authorities for the services they have provided?

Risk Declaration

Do you perform work offshore or onboard vessels?
Do you perform work at Oil & Gas, or Petrochemical sites?

Contact Information

First Name

Last Name

Phone

1	Name Year Appointed Academic Degree(s) Held Professional Qualifications (e.g. licensed Professional Engineer) Age
1	Name Year Appointed Academic Degree(s) Held Professional Qualifications (e.g. licensed Professional Engineer) Age

1	Entity Type Name % Ownership by Parent Organisation
1	Entity Type Name % Ownership by Parent Organisation

1	Type of Work Done No. of sub-contractors/consultants
1	Type of Work Done No. of sub-contractors/consultants

1	Claim Year Claim Amount Paid (SGD) Claim Resolved Claim Explanation
1	Claim Year Claim Amount Paid (SGD) Claim Resolved Claim Explanation