FIDELITY GUARANTEE INSURANCE PROPOSAL FORM
Address: Xxxxx 00, Xxxxxx Xxxxxxx Bank, 000, Xxxxx Xxxxxx, 00000 Xxxxx Xxxxxx.
Toll Free: 0-000-000-000 Tel.: 00-0000 0000 Fax: 00-0000 0000 E-mail: xxxx@xxxxxx.xxx.xx Website: xxx.xxxxxxxxxxxx.xxx.xx
Postcode | ||||||||||||||||||||||||||||||||||
FIDELITY GUARANTEE INSURANCE PROPOSAL FORM
Berjaya Sompo Insurance Berhad (62605-U) (BSIB) is licensed under the Financial Services Act 2013 and regulated by Bank Negara Malaysia. | |||||
IMPORTANT NOTICE | |||||
Non-Consumer Insurance Contract Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your trade, business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure for Non-Consumer Insurance Contract shall continue until the time your contract of insurance is entered into, varied or renewed with us. In addition to answering the questions in this proposal form, you are required to disclose any other matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this proposal form is inaccurate or has changed. | |||||
PLEASE USE BLOCK LETTERS AND CROSS (X) IN APPROPRIATE BOX | |||||
DETAILS OF PROPOSER | |||||
Name of Proposer (in full) : | |||||
Address (Postal): | |||||
Business/ Occupation : | Business Registraton No : | ||||
Period of Insurance : From to (Both Dates inclusive) | |||||
Employees to be insured (The amount of gurantee may be a specified amount over all or any group of employees.) | |||||
Item No. | No of Employees | Occupation | Amount of Proposed Guarantee | ||
1. What is the largest amount handled by any one employee at any one time? | |||||
(a) Cash | |||||
(a) Cheques | |||||
(b) Stocks | |||||
(c) Others (Please describe below) | |||||
(FGI/PF092018) 1
2. Systems/procedures relating to : Cash/Cheques |
(a) The number of signatories required to authorise payments and description of such authorised signatories. |
(b) The number of persons authorised to sign cheques and number of authorised signatories required for each cheque. |
(c) From what sources will money reach the employees' hands ? |
(d) Are all monies received banked by the following xxxxxx? Yes No If 'No', where are the money kept? |
(e) How ofren are bank reconciliation statements prepred ? |
(f) How often are bank books checked with Bank Statements, receipt counterfoils and vouchers, and any balance in hand by a responsible official independently of the persons making the Cash Book entries or paying into the Bank ? |
(g) Where employees are allowed to collect monies outside the office premises, are these accounted for daily ? Yes No If 'No', give details. |
(h) Are pre-numbered official receipts used as confirmation of the receipt of monies ? Yes No |
(i) How often are surprise cash counts on cash in hand including xxxxx cash and unpaid wages, done by an employee independent of the cashier ? |
(j) If cheque signing machines are used, what are the laid down procedures to ensure that signatures are only applied to properly authorised cheques ? |
(k) At what intervals will statements of account be sent direct by post to all customers, independently of employees in a position to receive payment of an account ? |
(l) Will all wages be prepared or checked in every detail independently of employees who handled the wages? Yes No |
(m) If employees handle any funds other than Employer's money and such funds are to be covered by the Policy, give full particulars showing what steps will be taken to ensure that they are properly accounted for. |
3. Stocks |
(a) Nature of stocks |
(b) Frequency of stocktaking |
(c) Persons responsible to carry out stock checks |
(d) Are services of a professional firm employed for stock taking ? Yes No |
(e) Who keeps the stock records? |
(f) Please advise security regarding : • Check of inward goods • Releasing of stocks from stores |
0.Xxxxxx Card Facilities |
(a) If these facilities are given to employees, please state the names and designation of these employees. |
(b) Are these employees allowed to use these facilities for personal expenses ? Yes No If 'Yes', please state the method by which such expenses are identified and settled. |
(c) Which person(s) are responsible for verifying the statements received? |
5. Please state the total number of salaried or wage-earning employees of all descriptions classified as follows : |
(a) Employees having responsibility for money and stock. I. Indoor employees (Executives, Managers, Cashiers, Clerk etc.) II. Outdoor employees (Salesman, Drivers etc.) (b) Employees not having responsibility for money and stock. |
Total : |
6. (a) Has it been your practice before engaging an Employee (other than those fresh from School and manual workers who will not be responsible for cash and stock) to satisfy yourself by written enquiry of previous Employers that the prospective Employee is of trustworthy character ? Yes No If 'No', give details. |
(b) Will such enquiries be made in respect of future entrants in your service ? |
(c) Will references obtained for employees be available in the event of a claim ? |
7.Are there any losses for the past three years ? If 'Yes', please give full details. | Yes No | ||||||||||
0.Xx your firm at present or has it in the past insured for any fidelity guarantee risks? If “yes” please state :- | |||||||||||
(a) Name of insurer(s) : | |||||||||||
(b) Amount Guarantee : | |||||||||||
(c) Gross premium | |||||||||||
(d) Period of insurance | |||||||||||
9.Has any insurance company : (a) Declined your proposal ? (b) Refused renewal of your policy ? (c) Required an increased premium or imposed a special condition ? If 'Yes', please give full details. | |||||||||||
10. System of check :- | |||||||||||
(a) Is a good system of records maintained and is it up to date ? | Yes No | ||||||||||
(b) Are the duties and authorities of each staff member clearly defined ? | Yes | No | |||||||||
(c) Is the division of responsibilities between departments, section and individuals well defined so that no person handles a transaction from beginning to end ? Yes No | |||||||||||
(d) Are independent checks of work carried out in the accounting, cash and stock sections ? Yes No | |||||||||||
(e) Is there a proper system of authentication of vouchers for payments ? | Yes | No | |||||||||
(f) Is there regular (at least once a month) balancing of cash and stock books and reconciliation with control records? Yes No | |||||||||||
(g) Is there a strict system of cash receipts control ? | Yes No | ||||||||||
(h) Is the system of daily bank deposits independently checked ? | Yes No | ||||||||||
(i) Is there a proper control of bank account operations and cheque books ? | Yes | No | |||||||||
(j) Is regular (at least monthly) bank reconciliations and checks of receipt counterfoils and vouchers made? Yes No | |||||||||||
(k) Are the approval and control of bills received carried out by responsible staff ? Yes No | |||||||||||
(l) Is there a regular balancing and control of debtor accounts with statements sent regularly to all debtors ? Yes No | |||||||||||
(m)Is there a responsible control of credit notes by senior accounting staff? | Yes | No | |||||||||
(n) Are perpetual records for all categories of stock assets independently maintained by physical control ? Yes No | |||||||||||
(o) Is there a close supervision of storage and custody of all stocks maintained? Yes No | |||||||||||
(p) Are all deliveries to and from stores properly authorised ? | Yes No | ||||||||||
(q) Are all dealings in investments authorised by Board and is there a control of registers, certificates, etc ? Yes No If 'No', give full details : | |||||||||||
(r) Is capital expenditure controlled by the Board ? If 'No', give details : | Yes No | ||||||||||
(s) Is there a regular independent system of internal audit of the activities of all persons to be insured ? Yes No | |||||||||||
(t) Is a full external audit (at least once annually) being carried out ? | Yes | No | |||||||||
PAYMENT METHOD | |||||||||||
Total Premium Paid: RM | Please select payment method. | ||||||||||
Cash | |||||||||||
JomPay | For payment via JomPay, please provide proo payment. | f | of | ||||||||
Visa MasterCard | Card No. - - - | Expiry Date m m / y y | |||||||||
Cardholder’s Name: | |||||||||||
Date: | Cardholder’s Signature: | ||||||||||
SERVICE TAX (ST) - ST will be imposed on the applicable portion of the premiums due and payable. | |||||||||||