Professional Indemnity Proposal Form

Data Protection

We are committed to protecting your personal data and privacy. Any personal information that we
collect will be kept confidential and will be processed in accordance with relevant legislation and
our own strict internal policy.
We will use any personal data we collect to process, evaluate the proposal and subsequently ,
administer your policy, service our relationship with you, provide you with products and services
and evaluate their effectiveness, provide you with better customer services and for statistical
analysis.
We may also, in carrying out your instructions, processing and administering your policy , transfer
your personal data to other Starr entities or third parties acting on our behalf where there may be
less stringent data protection laws. However, wherever it is held and processed, your personal
data will be protected by strict security measures which we and any third parties working on our
behalf are subject to, and will only be used in accordance with our instructions.
Your information may also be used for the detection and prevention of fraud and for audit purposes.
If you give us false or inaccurate information and we suspect fraud, we will record this. We may
pass your information to other Starr entities and agents working on our behalf, insurance industry
bodies, law enforcement and other legal agencies, governmental or judicial bodies, or to
regulators.
In order to assess the terms of the contract of insurance, information which the Data Privacy Act
of 2012 defines as ‘sensitive personal information. Your sensitive personal information will only be
disclosed to those involved with your proposal and policy or their agents. Your information may
be discussed with your agent or broker if you have requested the broker to assist you in handling
your insurance and you have authorised us to provide them with such sensitive personal
information.
We will not disclose your information to any other individual without your explicit consent. If you
want us to disclose your information to another individual or next of kin, you must tell us.

To help us ensure that your personal information remains accurate and up to date, please inform
us of any changes.
You have the right to see personal information about you held by us, to update or to correct your
personal information, and to lodge a complaint before the Philippine National Privacy Commission.

Please write to:

Data Protection Officer
Unit 5, 23rd Floor, Tower2, The Enterprise Center, 6766 Ayala Ave cor.
Paseo de Roxas, Legaspi Village, Makati City 1226

Under Republic Act 9180 (Anti-Money Laundering Act) as amended and pertinent regulations, all insurance
companies required to satisfactorily establish the identities of all its customers. Hence, Starr International
Insurance Philippines Branch reserves the right not to accept and process any application for insurance if
the customer fails to provide sufficient evidence to establish its identity
Philippines
We may, from time to time, provide you with marketing information about Starr, our products and
services and those of any associated companies which may be of interest to you. If you do not
want us to use your details in this way, please tick the box. 
You can find our full terms and conditions and details of our privacy policy at
http://www.starrcompanies.com/privacy-policy .

I. Applicant Details

1.1. Policyholder Name:

1.2. Address:
1.3. Date Established:
1.4. Website:

1.5. Has the Name of the Policyholder changed over the past 5 years: Yes No
1.6. Has the Policyholder’s name ever been changed, or purchased or merged Yes No
with any other practice or business?

If Yes to 1.5 or 1.6, provide additional details

II. Business Activities

2. Number of Staff by nature of work:

Number of Partners/Directors/Principals:
Number of Professional Employees:

Number of Other Technical Staff:

Number of Trainee Staff:
Number of Non-Technical Staff (admin, clerical, etc):

3. Qualifications of all Partners/Directors/Principals or other key professional personnel:

Name Qualifications Years in Years as Partner
Industry /Director/Principal

Under Republic Act 9180 (Anti-Money Laundering Act) as amended and pertinent regulations, all insurance
companies required to satisfactorily establish the identities of all its customers. Hence, Starr International
Insurance Philippines Branch reserves the right not to accept and process any application for insurance if
the customer fails to provide sufficient evidence to establish its identity
 Provide resume/CV of any of the above persons with less than three years experience in the relevant
industry

4. Provide full details of the activities of the Policyholder/Insured:

5. Provide details of any major new operations undertaken during the last 12 months or planned for the next
12 months.

6. Provide Percentage breakdown of business activities or advice by fee income:

Type of Work Percentage (%)

7. Professional organisations or associations which the Insured or principals are members of:

Under Republic Act 9180 (Anti-Money Laundering Act) as amended and pertinent regulations, all insurance
companies required to satisfactorily establish the identities of all its customers. Hence, Starr International
Insurance Philippines Branch reserves the right not to accept and process any application for insurance if
the customer fails to provide sufficient evidence to establish its identity
8. Please give the following turnover / fee income details:
Financial Year Currency Total
a) Previous Financial Year

b) Current Financial Year

c) Next Financial Year

What percentage of the turnover / fee income is derived from work in:
Philippines Other Asia Australia / Europe USA / Others Total
NZ Canada

9. List the countries with operation/location and staff number:

Country Number of Staff Country Number of Staff

10. Provide details of the 5 largest contracts carried out in the past five years:
Client Name Services Provided Location Year Fee income

Under Republic Act 9180 (Anti-Money Laundering Act) as amended and pertinent regulations, all insurance
companies required to satisfactorily establish the identities of all its customers. Hence, Starr International
Insurance Philippines Branch reserves the right not to accept and process any application for insurance if
the customer fails to provide sufficient evidence to establish its identity
III. Risk Management

11. Does the Insured execute written contracts or agreement with each client? Yes No

12. How are non-standard contact approved?

13. Are all changes to the Contract terms confirmed in writing? Yes No

14. Are verbal reports or advice always confirmed in writing? Yes No

15. Are written disclaimer included in any advice provided? Yes No

16. Subcontracting Work:

(a) What percentage of work is sub-contracted to others? ______%
(b) What services are being sub-contracted?

(c) Are sub-contractors require to carry their own Professional Indemnity insurance? Yes No

IV. Insurance History

17. Does the Policyholder currently have professional indemnity insurance? Yes No
If Yes, please provide details:
Insurer Policy Period Policy Limit (USD) Excess (USD) Retroactive Date

18. Has any application for similar insurance been refused, or has any similar insurance ever been rescinded
or cancelled? Yes No

Under Republic Act 9180 (Anti-Money Laundering Act) as amended and pertinent regulations, all insurance
companies required to satisfactorily establish the identities of all its customers. Hence, Starr International
Insurance Philippines Branch reserves the right not to accept and process any application for insurance if
the customer fails to provide sufficient evidence to establish its identity
19. What limit of liability is required for the Professional Indemnity insurance?

V. Loss & Claim History

20. Is any partner, director or principal after inquiry aware of any claims ever been made against the
Insured(s) or their predecessors in business or any of the present or former partners, directors or
principals? Yes No

21. Is any partner, director or principal after inquiry, aware of any circumstances or occurrences which may
give rise to a claim against the Insured or their predecessors in business or any of the present or
former partners, directors or principals? Yes No

If answers to any of the above questions is “YES”, full details of each matter must be provided before
quotation can be considered.

SIGNING THIS PROPOSAL DOES NOT BIND THE PROPOSER TO COMPLETE THIS INSURANCE

VI. Declaration

I/We declare that the statements and particulars in this application/ proposal are true and that no material
facts have misstated, misrepresented or suppressed after enquiry. I/ We agree that this application/
proposal, together with any other information supplied by me/ us shall form the basis of any contract of
insurance effected between the Insurer and me/ us. I/ We undertake to inform the Insurer of any material
alteration to those facts occurring before the renewal / completion of the contract of insurance.

Signed ................................................................

Title .................................................................
(to be signed by Partner/Director or Principal or equivalent)

Name .................................................................

Date .................................................................

Under Republic Act 9180 (Anti-Money Laundering Act) as amended and pertinent regulations, all insurance
companies required to satisfactorily establish the identities of all its customers. Hence, Starr International
Insurance Philippines Branch reserves the right not to accept and process any application for insurance if
the customer fails to provide sufficient evidence to establish its identity
Valid ID ……………………………………………….

VII. Please Enclose With This Proposal Form

• Corporate Profile / Brochure

• Latest Financial Statements / Annual Report
• Standard Contract or Agreements with clients
• Resume or CVs of all principals, partners or directors

Under Republic Act 9180 (Anti-Money Laundering Act) as amended and pertinent regulations, all insurance
companies required to satisfactorily establish the identities of all its customers. Hence, Starr International
Insurance Philippines Branch reserves the right not to accept and process any application for insurance if
the customer fails to provide sufficient evidence to establish its identity