POE INSURANCE - Application Form

【Basic Information】Notice: * is required

Legal Entity Name * : Kahaduwarachchi Yakupitiyage Sepali Dhammika

Registered Address * : 56 SALISBURY RD, BELLEVUE HILL NSW, 2023

Years In Business : 1

Contact Name : Kahaduwarachchi Yakupitiyage Sepali Dhammika

Contact Email * : lamarbossickdj@gmail.com

Insured Type : ☐ Company ☒ Personal

Business License/ID Card * ：(Accept all image formats, other formats need to be attached at the end)

For company please upload a copy of the company's business license and a copy of both side of the individual’s ID or passport (clear

photo/scan) / For personal please upload a copy of both side of the individual’s ID or passport (clear photo/scan)

Please click on the upper center to upload Please click on the upper center to upload
 Please click on the upper center to upload

Screenshot Legal Entity

Page * ：

Please click on the upper center to upload

Screenshot Legal Entity

Page (Example) ：

【Additional Insured】（If any）

If any, please enter the additional insured. If not, please leave it blank.

【Insured Store/Product】

Merchant Token： A3U40VXW8RYKHS

Notice: Please click to see how to find the merchant token

Store Link ： www.amazon.com/shops/rhymastic

Product Name ： Clothing, Home & Kitchen

Business Nature : Retailer

Estimated Annual Sales ： $200000 USD

Product Certification

Information (If any) ：

If any, please click on the upper center to upload

Product Category Sales Region (US/EU/AU)

Category 1 Clothing, Home US

Category 2 Kitchen US

Category 3 Please fill in your product category Please choose your region

【Insurance Protection Period】

Insurance Start Date： March 9, 2022 Insurance Protection Period： 1 year

【Loss Record】

Is there any products liability claim/loss or product recall in the past five years? (Default is no)

☐ Yes ☒ No

To add an attachment, select "Insert" -- select "Attachment" -- insert documents

Important Notice
a. This insurance application form is for quotation purposes only. Filling out this application form does not mean
that the applicant must apply for insurance or that the insurance company must underwrite.
b. Applicants may be required to provide other necessary information and copies of valid identification
documents so that the insurance company can accurately verify the identity of the applicant. By signing this
insurance application form, the insured and the insured agree that the insurance company collects information for
reviewing whether they meet the conditions of insurance.
c. In order to protect your own rights and interests, please carefully read and understand the provisions of the
insurance contract, especially the exemption from the insurer’s responsibilities, and listen to the explanations of
the insurance company’s business personnel before confirming to take out this insurance. Please make sure that
you fully understand the instructions of the insurance company's business leading to no objections. If there is no
inquiry, it is deemed that the content of the contract has been fully understood and which means there is no
objection.
____________________________________________________________________________
Statement
a. The company/unit hereby declares that this insurance application form has been completed after full
investigation by the company/unit, and the statements and details contained in it are true and correct, and there is
no misrepresentation or concealment of important facts.
b. The company/unit agrees that if the information contained in this insurance application form changes during
the period from the date the insurance application form is signed to the effective date of the insurance, in order to
ensure the accuracy of the relevant information on the effective date of the insurance, the company/unit shall
notify insurer the aforementioned information changes immediately, and the insurer shall have the right to cancel
or modify the relevant quotations, agreements or permits that bind the parties to conclude the insurance contract.
c. The company/unit agrees that this insurance application form is the basis for the conclusion of the insurance
contract, and as an attachment, it constitutes a part of the insurance contract.
d. The company/unit agrees that quotations, insurance clauses, insurance policies, endorsements or annotations
and other agreements are all part of the insurance contract.