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Comprehensive General Liability Insurance

GSIS insurance application form for comprehensive general

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN
(GOVERNMENT SERVICE INSURANCE SYSTEM)
Financial Center, Pasay City, Metro Manila 1308

COMPREHENSIVE GENERAL LIABILITY INSURANCE
(PREMISES LIABILITY ONLY)

Application Form
1. Business Name or Style:_______________________________________________
2. Registered Name: ___________________________________________________
3. Business Address: ____________________________________________________
4. Telephone Number: _________________________________________________
5. Fax Number:_________________________________________________________
6. Nature of Business:___________________________________________________
7. Occupied Space: ___________________________________________________
8. Total No. of Employees: ______________________________________________
9. Annual Sales: ________________________________________________________
10. Limit of Liability: ______________________________________________________
11. Has any Third Party Liability claim has been made against the proposer
during the last five (5) years for Bodily Injury or Property Damage?
( ) YES

( ) NO

If YES, please provide the details of each event, stating dates, description of
accident, number of casualties, property damaged, amount of claims,
status of the case, (please use back space for details).
I hereby declare that to the best of my knowledge and belief, all answers to
the above questions are true and complete.
______________________
DATE

__________________________________
Signature over Printed Name

PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN
(GOVERNMENT SERVICE INSURANCE SYSTEM)
Financial Center, Pasay City, Metro Manila 1308

COMPREHENSIVE GENERAL LIABILITY INSURANCE
APPLICATION FORM

I.

Name of Applicant ____________________________________________________

II.

General Information
a.

Location:
___________________________________________________________________
___________________________________________________________________

b.

Detailed Description of Applicant’s Operation:
___________________________________________________________________
___________________________________________________________________

General Liability
c.

Limits Required (BI and PD)
___________________________________________________________________
___________________________________________________________________

d.

Description of Hazards
(a) Premises Operations (as described under II-B)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Elevators – Description’ if any
_______________________________________________________________
___________________________________________________________
(b) Independent Contractors – Type and cost of work let or sublet.
What insurance do you require sub-contractors or independent
contractors to carry?
_______________________________________________________________
_______________________________________________________________
(c) Products - Lists of Products sold and estimated annual sales. (If
products coverage is required, please complete 5- Products
Supplement)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Government Service Insurance System
Comprehensive General Liability Application Form
Page 2 of 6

(d) Completed Operations - Length of time to be covered after
completion of construction, installation and/or repair work carried
out by the applicant of for which the applicant is liable.
_______________________________________________________________
______________________________________________________________________

_______________________________________________________________
(e) Contractual
(i)

Effective date of Agreement(s)
_________________________________________________________

(ii)

Names of Parties to the Agreement(s)
_________________________________________________________
__________________________________________________________

(iii)

Wording of Assumed Liability of Hold Harmless Agreement
(attach)

_________________________________________________________

____________________________________________________
1. Premises Operations – Miscellaneous
Does Applicant own, rent, lease, or operate any property such as
sales offices, mercantile or office buildings, apartment buildings,
theatres, warehouse, stores, residences, or states? Is he
concessionaire on anyone else’s property?
_______________________________________________________________
_______________________________________________________________
(a) Own, rent, lease, or occupy and land, farms, camps, docks, or
wharves?
_______________________________________________________________
_______________________________________________________________
(b) Use or advertise through the medium of signs, posters, bulletins,
placards, street banners, etc. Which are placed on premises not
occupied by the applicant?
_______________________________________________________________
_______________________________________________________________
(c) Act for any property in the capacity of trustee, executor,
administrator, guardian, receiver, or in any other fiduciary
capacity or as a managing agent?
_______________________________________________________________

Government Service Insurance System
Comprehensive General Liability Application Form
Page 3 of 6

(d) Sublet any portion of premises he owns, rents, leases, or
occupies?
_______________________________________________________________
_______________________________________________________________
(e) Does any installation repair or construction work off the premises?
_______________________________________________________________
_______________________________________________________________
(f) Demonstrate goods or products away from the premises?
_______________________________________________________________
______________________________________________________________
(g) Contemplate any new construction structural alterations or
demolition?
_______________________________________________________________
_______________________________________________________________
(h) Rent or lease mechanical equipment to or from others?
_______________________________________________________________
_______________________________________________________________
(i) Own or operate any railroad, locomotives, freight, cars, individual
trucks, etc.
_______________________________________________________________
_______________________________________________________________
(j) Sell or use explosives?
_______________________________________________________________
(k) Own or operate any watercraft or aircraft? If so, are passengers
carried for a consideration?
_______________________________________________________________
_______________________________________________________________
(l) Act as stevedore?
_______________________________________________________________
_______________________________________________________________

Government Service Insurance System
Comprehensive General Liability Application Form
Page 4 of 6

(m) Own or occupy an industrial village? If so, explain full, giving
number of residences, churches, theatres, and street mileage.
_______________________________________________________________
_______________________________________________________________
(n) Have any joint operations with others?
_______________________________________________________________
_______________________________________________________________
(o) Own or use any dogs away from the insured premises?
_______________________________________________________________
_______________________________________________________________
(p) Employ any nurses, doctors, or dentists?

__________________________________________________________
_______________________________________________________________
(q) Maintain any hospital, infirmary, clinic, and first aid station?
_______________________________________________________________
_______________________________________________________________
(r) Own or operate any beauty parlor, barbershop, bathhouse,
drugstore, swimming pool, sanitarium, health institution, etc.?
_______________________________________________________________
_______________________________________________________________
(s) Is there any professional or malpractice exposure?
_______________________________________________________________
______________________________________________________________
(t) If malpractice or professional exposure is let out on concession,
does concessionaire carry professional liability coverage? If so,
state policy term and limits carried.
_______________________________________________________________
_______________________________________________________________
(u) Engage in operations involving quarrying or underground mining?

__________________________________________________________
__________________________________________________________

Government Service Insurance System
Comprehensive General Liability Application Form
Page 5 of 6

(4) What is the insured’s source of the following?
(a) Water supply_____________________________________________
(b) Milk supply _______________________________________________
(c) Food supply ______________________________________________
(d) Electrical supply ______________________________________

(5) Products Supplement
(a) Describe and list separately, in the manner requested below,
all products manufactured handled, distributed or sold by applicant:
______________________________________________________________
______________________________________________________________
(i) Products manufactured or prepared by applicant or which
bear applicant’s name or label.
_____________________________________________________________
_____________________________________________________________
(ii) Products handled, distributed, or sold which do not bear
applicant’s name or label which are manufactured and
prepared by others.
_____________________________________________________________
_____________________________________________________________

(iii) Please attach samples of catalogues or other advertising
material
with labels and printed wrappers, which describe
the above products and their use.
______________________________________________________________
______________________________________________________________
(b) How long has the applicant operated on this business, how many
products are added each year and what are the equally controls?
(If applicant is a branch operation these questions refer to the
branch.)
_____________________________________________________________
_____________________________________________________________
(c) Have there ever been any products suits or claims against
applicant’s local office? Give particulars and costs of settlement, if
any.
_____________________________________________________________
______________________________________________________________
(d) Does applicant’s organization, issue any guarantee of products?
If so, please give details.
______________________________________________________________
______________________________________________________________

Government Service Insurance System
Comprehensive General Liability Application Form
Page 6 of 6

(e) What is Insured’s estimate of Annual Payroll P____________________
(f) What is Insured’s annual sales by country?
a) to U. S. A
P__________________
b) Philippines
P__________________
c) Other Countries (Please specify)
1.
P__________________
2.
P__________________
3.
P__________________
(g) What measures have been taken in bottling/packaging of
consumer products to make them tamper-resistant?
________________________________________________________________
________________________________________________________________
(h) Is there a product liability committee in the organization of the
insured?
□ YES
□ NO

(i) Has assured developed any product recall procedures?
□ YES

□ NO

(j) Are labels and warnings clear and simple?
□ YES

□ NO

(k) Is advertising checked to guard against excessive claims (some
ads indicate wordings “completely safe” as an example? This
presentation could result to injured costumer’s filling major claim
against the insured.)
□ YES

□ NO

(l) Were there products discontinued by the Insured? If yes,
indicate list of products discontinued, estimate of unit counts or total
sales in the market before discontinuance and reasons for
discontinuance.
___________________________________________________________________
___________________________________________________________________
The liability of the company does not commence until this proposal has been
accepted, the policy issued and the premium is paid.
 
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